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introduction 1homeless men and substance use homeless populations are at significantly higher risk for substance dependence with rates of drug and alcohol abuse two to eight times higher than in the general population drug and alcohol use is associated with multiple deleterious health consequences and vulnerability factors associated with living on the street may create riskier patterns of substance use and exacerbate the homeless populations already high rates of health problems and hospitalization men are more likely than women to be homeless to experience longer episodes of homelessness and when homeless more likely to be drugand alcoholdependent this study investigates key individual characteristics and social network risk and protective factors that may be associated with substance use among a highly vulnerable population of homeless men living in the skid row area of los angeles california social context of substance use research has identified social network characteristics as important factors in understanding substance use among homeless and other highrisk populations the composition of individual personal networks may have both direct and indirect effects on substance use for example other drug and alcohol users in the network may provide substances or paraphernalia to facilitate use or may indirectly encourage substance use by displaying social norms supportive of drugs and alcohol the association between network composition and substance use has been supported by research among homeless populations more alcohol and drug users in homeless womens personal networks were associated with binge drinking and drug use and having used illicit drugs with network members or having peers who regularly use drugs were associated with increased severity of substance use among homeless young adults quality of relationships with members of the network has been associated with substance use increased social support from those in the network has been associated with decreased drug use in highrisk communities and the perception of increased social support was associated via decreased levels of emotional distress with reduced substance use among sheltered homeless in skid row social support from substance users however does not confer the psychosocial and health benefits provided by nonsubstance using networks among homeless women social network density has also been associated with substance use it is hypothesized that increased network density may result in a spiral of silence wherein any discussion that runs contrary to network norms may be avoided for fear of disrupting the network resulting in the maintenance of risky behaviors within densely interconnected networks subgroups of alcohol or drug using network members may be especially vulnerable to the maintenance of substanceusing norms mental health and substance use previous research highlights the association of mental health problems with substance use and the high prevalence of mental health problems among homeless persons while there is heterogeneity in specific study rates a recent review of the literature suggests high rates of depression among homeless populations because depression has been associated with alcohol and drug abuse homeless men may be at increased risk of substance use related to depression posttraumatic stress disorder has also been associated with substance use including the selfmedication of ptsd symptoms with cns depressants homeless persons are exposed to a variety of stressors that may make homelessness itself a risk factor for ptsd most research on trauma and homelessness has focused on women and families despite the fact that nearly 70 of homeless men with cooccurring mental health and substance use disorders report histories of trauma the cooccurrence of mental health problems and substance use suggests that both must be examined to fully understand substance use among homeless men 14the present study this paper is motivated by social norms theory which posits that individual substance use behavior is associated with the perceived behavior of social ties empirical research has confirmed that social networks represent a meaningful and important level of analysis for understanding the relationship between social norms and risk behavior prior studies of substance use and social networks that have included homeless men in the study population have utilized smallscale qualitative methods or convenience samples to our knowledge no previous study has conducted a thorough investigation of personal networks and their association with substance use in a representative probability sample of heterosexually active homeless men a comprehensive understanding of the social context may help to inform peerbased interventions to reduce the harmful effects of substance use in this highly vulnerable population previous research with similar populations directs us to hypothesize that network composition and structure including greater network density increased substance use in the network and decreased social support as well as key individual predictors will be associated with increased substance use in this population methods sample design to obtain a representative sample of heterosexually active homeless men from the skid row area of la we implemented a probability sample of men recruited from meal lines in the area the list of operating meal lines in skid row was developed using existing directories of services for homeless individuals and performing interviews with services providers our final list contained 13 meal lines 5 breakfasts 4 lunches and 4 dinners offered by 5 different organizations each of the meal lines was extensively investigated to obtain an estimate of the average number of men served daily this information was used to assign an overall quota of completes to each site approximately proportional to the size of the meal line we then drew a probability sample of homeless men from the 13 distinct meal lines when the assigned quota could not be achieved in a single visit the quota was divided approximately equally across the number of visits for each meal line the interview team randomly selected potential recruits for screening by their position in line using statisticiangenerated random number tables tables were generated such that the sitedaily quota could be achieved before the meal line was exhausted once the field director selected a potential recruit an interviewer would wait for him to finish his meal before screening him the adopted sample design deviates from a proportionatetosize stratified random sample because of changes in sampling rates during the fielding period differential response rates of men across meal lines and variability in how frequently men use meal lines this last factor means that some men are more likely to be included in the sample we accounted for the differential frequency of using meal lines by asking respondents how often they had breakfast lunch and dinner at a meal line in the skid row area in the past 30 days and how much of the past 6 months they had been homeless this information was used to develop and implement sampling weights to correct for departures from a proportionatetosize stratified random sample and potential bias due to differential inclusion probabilities measures 231 substance usebinge drinking was assessed through a question asking men how often during the prior six months they had 5 or more drinks containing any kind of alcohol within a 2 hour period use of other substances was assessed using separate questions for marijuana crack cocaine prescription drugs heroin methamphetamine and other substances for each substance the men were asked during the past six months how often did you use dichotomous indicators of any binge drinking and substance use were created from these measures binge drinking items and response scales were modified from niaaa task force recommendations and all substance use items have been previously vetted with a population of homeless women and our experiences in a prior study of homeless women to develop the instrument we asked respondents to provide the first names of 20 individuals that they knew who knew them and that they had contact with sometime during the past six months contact could be facetoface by phone mail or through the internet we constrained network size to be the same across respondents to maximize comparability of network structure measures twenty alters has been shown to capture structural and compositional variability present in personal networks four men who were not able to name 20 alters were excluded from the sample to maintain comparability across cases personal network characteristicswe used established procedures for conducting personal network interviews we measure characteristics of networks in terms of alter types and behaviors how alters were met and the overall structure of each respondents personal network types of alters that we inquired about form mutually exclusive categories sex partners relatives persons in positions of responsibility and peers and acquaintances for all nonrelative alters we asked how the respondent met these individuals persons in positions of responsibility refer to service providers teachers bosses or supervisors and probation officers other nonfamily nonsex partner alters were categorized as peers and acquaintances we assessed behaviors of the 20 alters as perceived by the respondents heavy drinking drug use and regular employment to measure the frequency contact with alters respondents were asked how often they contacted each named alter and an average was calculated across all alters we calculated proportions of total alters whom respondents reported feeling emotionally close to and those from whom the respondent received tangible or adviceinformational support in the prior six months network structure was operationalized as density an index varying between 0 and 1 that represents the proportion of ties among a group of alters relative to the total number of possible ties for the purposes of calculating density respondents were asked how often each pair of named network alters had contact with each other sometime during the past year or so either facetoface by phone mail or email never rarely sometimes or often measures of network density were calculated among all network alters and among those alters who were reported by the respondents as being likely to use drugs or alcohol to intoxication most measures of network composition were included as continuous proportions of the total network however two specific measures were skewed in that many respondents had no network alters meeting these criteria and so these measures were included in analyses as binary indicators rather than total network proportions depression and ptsddepression was measured using a 3item screening instrument that has been previously used to assess depression in homeless persons ptsd was measured with the primary care ptsd screen a 4item screener used with veterans respondents are defined as experiencing symptoms of ptsd if they answer yes to any three of four items background characteristicsbackground characteristics included in all models are age in years education being employed partor fulltime being currently married having been in jail prison or on parole in the prior 6 months and raceethnicity analyses overall rates of substance use during the past 6 months were calculated for binge drinking and use of marijuana crack cocaine heroin prescription drugs methamphetamines and other substances we elected to include the three substances having the highest prevalence rates among homeless men in this study binge drinking marijuana and crack other substances had prevalence rates ranging from 477 to 1679 we first examined the bivariate association between each individual and personal network characteristic and each of the three measures of substance use each candidate predictor variable associated with any substance use measure at p 10 in the bivariate analyses was retained in initial multivariate models for all outcomes we then trimmed from the multivariate models all variables that were not significant at p 10 for at least one of the three outcomes 1 individual demographic characteristics were retained in all models as control variables 1 african americans were the largest racialethnic group in our sample followed by men selfidentified as white hispanic and other or multiracial most respondents had a high school diplomaged but only 18 were currently employed few were currently married 3731 were incarcerated in the prior six months and 1864 had ever been in the military the average total months of lifetime homelessness was 6461 representing an average of 1107 of mens lifetimes 945 of men had spent at least one night on the street in a garage or an abandoned building nearly half the sample had experienced symptoms of depression or ptsd results sample characteristics individual characteristicsas shown in table personal network characteristics the majority of mens networks were comprised of peers among the 20 named alters there was an average of 58 peers 22 relatives and 15 sex partners the remaining 5 were persons in positions of responsibility though only 3393 of the total sample reported any of these alters most network alters were met on the street followed by at a shelter and at employment or school less than a quarter of the respondents had met any of their network alters in a bar or club an average of 48 of an individuals personal network was comprised of alters with regular employment about onethird of network alters drank alcohol to intoxication or used drugs in the past six months and 20 had engaged in risky sex on average respondents felt emotionally close to 32 of their alters and received support or advice from 36 the average frequency of contact among network alters was 207 representing 13 contacts each month the average density of mens personal networks was 013 which can be interpreted as a network in which 13 of all possible ties are present the average percentages of possible ties present in substanceusing subgroups were lower at 11 in alcoholusing subgroups 9 in drugusing subgroups and 8 in subgroups who used both alcohol and drugs substanceusing subgroups appear to have less integration between network members than the overall network however these densities were not statistically significantly associated with substance use multivariate logistic regression models table 2 presents the results of multivariate logistic regression modeling any binge drinking and any use of marijuana or crack in the past 6 months each substance is modeled separately and trimmed models are presented odds ratios can be interpreted as the increase in odds of using the particular substance in the past six months attributable to a unit increase in the associated predictor mens personal network characteristics were associated with binge drinking marijuana and crack use homeless mens odds of binge drinking were increased when their networks included alters whom they met at a bar or club men with more drug users in their networks had increased odds of marijuana use men had decreased odds of using crack if they had more family members in their social network met more network alters at a job or school met alters at a bar or club or had more employed alters several individual characteristics were also associated with binge drinking and drug use younger men were more likely to binge drink and use marijuana white men were significantly more likely than african american hispanic or other and multiracial men to use marijuana whereas hispanic men had nearly 8 times greater odds of using crack than white men prior 6 months incarceration was associated with increased crack use mental health status was also associated with substance use as homeless men with symptoms of ptsd had significantly increased odds of using crack discussion binge drinking marijuana and crack use were each associated with different aspects of individual social networks consistent with findings from prior studies of homeless women social network features appear to confer both protective benefits and risks for substance use among heterosexually active homeless men living in the skid row area a higher proportion of drug users in ones network was significantly associated with marijuana use confirming prior research that drug using ties are associated with individual drug use having drugusing members in the social network may provide direct support for marijuana use perhaps by providing drugs or paraphernalia or may indirectly support use through social norms accepting of marijuana this relationship may also be the product of homophilous network selection wherein substance users associate with other substance users because they frequent the same locations or use the same substances social selection may work in concert with attitudinal influences such that selection of similar alters reinforces network norms and vice versa the limitations of crosssectional data make it difficult to parse out the causal direction between norms and network selection in this study the context of relationship formation may also influence homeless mens substance use via pathways dependent upon the substance in question having met network alters at a bar or club was associated with increased binge drinking but this measure was also associated with decreased crack use the normative behavior of alters whom homeless men met at a bar or club may encourage alcohol use which is readily available and legal in these settings but may discourage the use of illegal or stigmatized substances like crack a similar pattern was seen in prior research among homeless women where heavy drinking networks were less likely to use crack suggesting that social normative influences differ between drug and alcohol using networks crack use was also more likely among men with fewer family employed and schoolwork network ties these patterns support prior research findings that normative social ties such as family members and employment or educational contacts may have social norms protective against the use of stigmatized drugs increased social support has been shown to affect substance use in other communities but was not significantly associated with substance use among homeless men in this study prior studies of homeless women have suggested that social support alone may not be sufficient for recovery in the face of addictive substances such as crack additionally social support measures in this study did not specifically pertain to drug use other forms of social support such as assistance navigating barriers to substance abuse treatment may be of specific importance for homeless men individual characteristics are also important factors in the substance use of homeless men including symptoms of psychological distress associated with ptsd prior research has linked symptoms of ptsd to substance abuse among homeless and other populations while this study does not differentiate between casual use and abuse of drugs ptsd was associated only with crack the most stigmatized of the substances we examined and one that carries high potential for abuse due to its psychopharmacological properties in addition to the causality limitations inherent in a crosssectional design other limitations exist in this study men who are currently residing in shelters or treatment facilities may be subject to policies of substance abstinence which could have impacted the level of substance use reported selfreported substance use may raise concerns about bias however selfreported measures have been found to be highly correlated with objective measures of substance use among homeless women and have been successfully used in other studies investigating substance use among homeless persons this population was part of a study of heterosexually active homeless men and while there was representation of men who have sex with men and women these results may not be generalizable to populations comprised exclusively of men who have sex with men sampling from meal lines may further limit the generalizability of the findings as all men in this study were accessing services at least to receive meals however we believe that probability sampling from meal lines which serve a wide population is an innovative approach for generating a more representative sample when compared to other methods such as convenience sampling which are traditionally utilized in this population despite these limitations this study has successfully identified important aspects of homeless mens social networks and mental health status that are associated with binge drinking and drug use social network interventions particularly peerbased educational models have been successful in reducing the risk behavior of intravenous drug users while this study did not examine intravenous drug use the findings that social network peers may be important determinants of other substance use suggests that similar interventions could reduce substance use among homeless men findings that environmental factors such as where alters were met were associated with substance use also speaks to the potential efficacy of venuebased interventions to encourage risk reduction family employment and schoolbased alters were also associated with decreased substance use so other interventions might facilitate the maintenance of such contacts increased availability of internet and phone access might be one way to encourage contact with these prosocial alters who are less likely to be streetbased further the cooccurrence of ptsd and substance use in this study suggests that mental health needs should be addressed concurrently with substance abuse and that network interventions to reduce substance use might also encourage helpseeking for mental health problems these findings underscore the importance of substance abuse interventions that take into account both mental health and the context of the social network

backgroundhomeless men may be at particular risk for the negative health effects of substance use this crosssectional study investigates the individual and personal network risk factors associated with substance use in this vulnerable population methodsparticipants were a representative probability sample of 305 heterosexually active homeless men interviewed from meal programs in the skid row region of los angeles california interviews assessed individual personal network and substance use characteristics logistic regression examined individual and personal network predictors of the three most prevalent substances resultsin the past six months the three most prevalent substances were marijuana 56 crack 40 and alcohol to intoxication 38 the mental health status of homeless men was associated with substance use with ptsd more common among those who used crack riskier networks comprised of a larger proportion of drug users were associated with marijuana use and normative social ties family employed and schoolwork contacts were associated with a decreased likelihood of crack use conclusionsmental health problems and riskier personal networks are associated with homeless mens substance use these findings underscore the importance of interventions that focus on improving mental health mitigating the drugusing norms of personal networks and helping men to maintain contact with normative lowrisk alters mental health care and peerbased network interventions to reduce substance use should be a priority for heterosexually active homeless men

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introduction advance care planning is defined as a process that supports individuals in understanding exploring discussing and documenting their personal values life goals and preferences for future medical care and entails communication with loved ones caregivers or healthcare professionals 1 acp was included in the world health organizations global dementia observatory framework 2 which strives to increase awareness in dementia as a public health priority and to advocate for action at national and international levels one of the global action areas under this framework was to improve endoflife care in persons with dementia by promoting awareness on acp respecting the values and preferences of pwd and empowering pwd to make choices about their care acp encourages people to engage in discussions about future health choices and medical care from the patients perspective acp prepares them for death and dying allows them to exercise control and relieves loved ones of the burden of decision making 3 4 5 there has been an upsurge in research publications in the last decade on acp for persons with dementia 6 however compared to individuals with a chronic medical illness such as heart failure and endstage renal disease 78 the effectiveness of acp in pwd on clinical outcomes has not been extensively studied 910 with limited examination and synthesis of scientific evidence for improving acp in dementia 11 this group of vulnerable individuals is at risk of decisional incapacity given the natural course and progression of the dementing illness due to the length of illness caregivers of pwd also often experience prolonged burden in their caregiving role that places extreme stress on prior relationships 12 thus acp when conducted in the early stages of dementia can be an important gift of legacy for the family although the optimal timing for acp in dementia remains to be established the earlier stages afford a limited window of opportunity when pwd are still able to indicate their preferences and designate their preferred surrogate decision maker 13 despite the many benefits of administering acp early in pwd 14 15 16 there are barriers encountered prior to engaging them for acp discussion viz uncertainty in decision making existential and emotional barriers timing of acp discussions lack of understanding of acp distrust in healthcare professionals and unequipped healthcare systems 17 18 19 20 a conceptual framework has been proposed that aligns these perceived barriers to the different steps of the acp process namely precontemplation contemplation preparation and values clarification actions and maintenance or reflection on ones choices 21 using this conceptual framework the care recipient caregiver and physicianrelated barriers to contemplation discussion and documentation have been reported at various steps of the acp process 22 23 24 25 26 27 the current model addresses the general and common barriers to acp with particular emphasis on care recipientrelated barriers to promote health behavior change 22 emerging literature highlights the unique influence of sociocultural factors above and beyond conventional barriers in the contemplation stage thus hindering the actual initiation of acp in dementia 2528 for instance in the chinese culture it is often considered taboo to discuss matters pertaining to death as this can be deemed inauspicious or even disrespectful 2930 dementia itself is also viewed as a taboo topic hence asians are reticent to discuss it another important barrier to acp within the asian context is that asians generally adopt a rather passive attitude in the management of their illnesses often opting to leave decision making on endoflife treatment to their family members 31 32 33 34 this contrasts with the western culture which places emphasis on individual autonomy in decision making 35 with dementia and acp both highly regarded as taboos in the asian culture the conduct of acp discussion has to be diseasespecific and culturally tailored 36 before any intent or contemplation can occur to promote a behavioral change towards initiating acp in addition the impact of sociocultural influences on care recipient or caregiver perceptions of acp in dementia in asian populations has hitherto not been systemically studied and the influence of spirituality religion and traditional chinese philosophy on acp is not well understood 37 acp in singapore was first introduced by respecting choices of wisconsin united states of america in 2009 38 singapore a southeast asian country is a multicultural multiethnic and multireligious society with english being the countrys default cultural lingua franca that unite various ethnic groups chinese singaporeans make up the majority of the population followed by malays ethnic indians and eurasians singapores healthcare system is traditionally paternalistic 30 such that the authority of physicians is often not disputed and healthcare decisions are medically guided the populations cultural and ethnic diversity can explain the influence of traditions and beliefs on healthcare utilization behavior and medical decision making acp was a novelty then and was initiated in people with advanced illness such as advanced heart failure and respiratory disease in 2011 a national acp program was established and there was a progressive nationwide adoption of acp over the last decade however there is still no structured dementiaspecific or dementiafocused acp to date we conducted a pilot project of acp discussions with patientcaregiver dyads early in the course of dementia in a memory clinic in singapore we aimed to examine the disparity in perceptions among subjects with mild dementia and their caregivers towards acp after undergoing acp counseling and explore the barriers to acp in dementia materials and methods study design a parallel mixedmethod study design was conducted whereby the quantitative and qualitative data were collected concurrently mixedmethods research is underpinned in the pragmatic research paradigm its comprehensive approach and employment of diverse data sources yield a broader picture and more comprehensive support for validity in the investigation of an underlying phenomenon such as acp in realworld practice 39 in our study we wanted to obtain different yet complementary data to examine the perceptions of pwd and their respective caregivers on acp which was then a novelty in singapore the central phenomenon to be explored was the perceived barriers to the initiation of acp discussions in pwd and their caregivers in a memory clinic setting in singapore study population subjects were recruited from the outpatient attendees of the memory clinic at a tertiary hospital over a period of 25 years we recruited patients who were newly diagnosed with dementia based on the diagnostic statistical manual 4th edition criteria and also fulfilled the following conditions mild severity as defined by a global clinical dementia rating score of 051 no significant mood disorders or behavioral problems and had an identified caregiver who was conversant in english we excluded those with moderate or severe dementia or who had a concomitant diagnosis of delirium as they might not be able to fully understand or participate actively in the conversations pertaining to acp due to the novelty of acp in singapore then those with unstable medical conditions defined as more than 2 hospitalizations in the last 1 month prior to recruitment were also excluded since they were still in recovery from acute episodes of their illness participant information sheets were given to eligible patientcaregiver dyads as assessed by their primary physicians prior to consent taking and participation in the study was entirely voluntary informed consent was obtained from patientcaregiver dyads in the comfort of a private room within the hospital both patients and caregivers were encouraged to ask questions and clarify any doubts that they might have prior to consenting to the study all study participants were assigned unique code numbers to maintain anonymity and confidentiality all survey data and interviews were deidentified and stored securely with restricted access by the study group the conduct of the study was approved by the institutional review board of the national healthcare group data collection we collected patients demographic data including age race gender education level comorbidity burden functional data of basic activities of daily living instrumental activities of daily living cognitive assessment and measures of caregiver burden we also collected caregivers demographic data such as age gender years of education relationship and coresidence with patient acp counseling the dementia nurse a trained acp facilitator scheduled an acp counseling session with the patients and their respective caregivers after they had been apprised of the dementia diagnosis the content of the session was tailored towards acp discussion in the context of dementia and entailed educating patientcaregiver dyads on acp exploring their fears and concerns in initiating acp and discussions on preferred future care plans the session was conducted in the form of a semistructured interview and usually lasted for an hour a short debriefing session was arranged to address any concerns or queries that might have surfaced during the counseling session and followup plans were carried out if required prepost acp counselling questionnaires each patientcaregiver dyad was given a questionnaire before and after the acp counseling session and they were surveyed individually we modeled the framework of our questionnaire after a study by fried bradley towle and allore 40 and developed a culturally acceptable questionnaire the prepost counseling questionnaires assessed the patientcaregiver dyads perceptions of acp and explored their understanding of the purpose of basic acp and their attitudes and feelings about endoflife communication with each other in particular their understanding of the illness willingness to have further discussions and the acknowledgement of barriers to communication the postcounseling questionnaire also assessed their experience during acp counseling qualitative interview either one of the two principal investigators met up with the patientcaregiver dyad a minimum of a week later after the acp counseling session the qualitative interview occurred at the patients place of residence or in a private room in the hospital it usually lasted between 20 min to 1 h an audiotape recorder was used to record the entire interview and conversations were then transcribed verbatim the interview aimed to accomplish the following objectives to enable the subjects and caregivers to elaborate further on their perceptions and feelings with regards to acp and to identify barriers to acp discussion quantitative and qualitative data analysis we employed concurrent collection analysis and interpretation of the quantitative and qualitative data for this study 41 we conducted descriptive analyses of the baseline patient and caregiver characteristics and univariate analysis by fishers exact test to determine the differences between the patientcaregiver dyads responses to the questionnaires in particular for this paper the endoflife communication between patients and caregivers statistical package for the social science software version 190 was used for quantitative analysis and a p value of 005 was considered to be significant results from the quantitative analysis helped to inform the interpretation of the qualitative data about barriers to acp for the qualitative data analysis data from the interviews were analyzed using thematic analysis by two qualitative researchers thematic analysis 42 is a process for encoding data that involves breaking down of data into codes and then organizing codes data into thematic sets it involves searching across a data set to find repeated patterns of meaning to allow themes to emerge from the data via an approach that is interpretive descriptive and inductive epwh and vd coded the data from the transcripts separately using linebyline coding and initial codes were generated anonymity of the transcripts was assured with removal of patientcaregiver dyads identifiers both researchers met to compare the initial codes and an agreement was reached between them to decide on the final focused codes any disagreement was resolved through consensus the focused codes were then raised to conceptual categories and themes that were generated were subsequently compared with the literature obtained prior to the interviews memos were written to determine the data that needed to be collected during subsequent rounds of data collection to enhance the understanding and insights that were gathered from previous interviews the selected themes and quotes were reviewed and endorsed by the rest of the research team integration of both quantitative and qualitative data into a single database enabled the research team to further analyze and simultaneously interrogate the data with equal weightage to examine the patientcaregiver dyads perceptions of acp and explore the barriers to initiation of acp results characteristics of the patientcaregiver dyads we identified 30 patientcaregiver dyads for the study of which 20 agreed to participate reasons cited for nonparticipation include not keen too busy dont want to talk about acp and worried if the discussion will cause patient to be depressed among the 20 patientcaregiver dyads who underwent acp counseling two declined further interviewing and one did not complete the postcounseling questionnaire table 1 depicts the baseline characteristics of the 20 patientcaregiver dyads patients who underwent acp counseling had a mean age of 759 years were predominantly male welleducated and of chinese ethnicity their mean cmmse score of 228 corresponded to their mild stage of dementia predominantly of alzheimers disease etiology they were not functionally impaired as is evident in the mean score of 149 on the iadl scale and were healthy with few comorbidities based on their low charlson comorbidity index score of 46 the majority of caregivers were males highly educated and either adult children or spouses disparity in patientcaregiver dyads perceptions on acp prior to acp counseling only 30 of the patients and 50 of the caregivers had heard of acp although 70 had thought of their healthcare proxy only 30 of the patients had made future care plans prior to acp discussion there were notable differences in perceptions between the pwd and caregivers as shown in table 2 before acp counseling 85 of patients surveyed agreed with the importance of communicating to their caregivers about their illnesses and 55 would like further discussion with their caregivers after acp counseling more patients were keen for further discussions despite a reduced proportion who understood the importance of talking about their illness in contrast despite undergoing acp counseling a higher percentage of caregivers acknowledged barriers to communication with a concomitant decline in the number of caregivers who were keen to explore acp further postacp counseling caregivers were significantly more likely to acknowledge barriers to acp discussions than patients compared to patients caregivers were also more likely to find acp useful in understanding complications of illness though more caregivers found acp helpful in exploring their preferences for future treatment the difference was not statistically significant barriers to acp thematic analysis of the transcripts revealed several barriers to acp they can be categorized into patientrelated factors caregiverrelated factors sociocultural factors and the inappropriate timing of the discussions in our asian culture filial piety and family togetherness are greatly emphasized not surprisingly elderly patients tend to take on the dependent role and entrust their children with the burden of care and with any decision making about future care plans this transference of care was evident in some respondents who indicated that they would readily leave family members to liase with the healthcare team about treatment decisions this reinforces their own dependent role in the decisionmaking process and effectively transfers the burden of decision making to the proxy family member inevitably this downplays the perceived need for discussion with caregivers about their personal preferences for future treatment well thats left to the children how best they can look after me and to make sure that i have the best treatment although they know it may be terminal poor cognition and perceived lack of understanding poor cognitive functioning and the ensuing perception that patients might not understand or be able to engage in advance care planning was viewed as a reason for not discussing acp yes there is a barrier but the problem is that um shes not able to actually understand what we are asking no i dont talk to her about the future because you know i can talk to her about the future then the next day ill tell her did you remember shell said no lack of inclination to plan for the future when asked about their willingness to hold further discussions with their caregivers about their future care most of the patients did not see the necessity they cited difficulties in planning for their future due to the uncertainty in the manner and timing of disease progression there was no urgency in initiating acp discussion or plan for the future since there was no compromise in their present health status instead of being preemptive they were quite content to adopt a more passive waitandsee approach some of them displayed imperturbable and cavalier attitudes towards acp because nothing happen to me just be happy there is not much feeling my condition is okay ive got nothing to worry about nothing its better to forget all the unhappiness those are not important to me caregiverrelated factors perceived negative impact on patients although the majority of caregivers described the session as being important one caregiver was concerned that discussion of endoflife issues would cause anxiety in patients and another caregiver felt that such sessions might not be appropriate for everyone a concern was voiced by some caregivers that discussing such issues would result in further deterioration of the patients health and would negatively influence the patients decisions i think they are afraid when they dont want the sick to get worse theyre afraid and we all too will get afraid i think as i said if i get round to this stage where i have to go on life support caregivers discomfort there was a certain degree of discomfort and difficulty in broaching the topic of acp to their loved ones among the caregivers in view of the sensitivity of the issues that may arise during the discussion im very glad that this session has taken place and he has been very frank and open and now i also know his wishes because its a very sensitive topic and it is even though we love one another it is very difficult to approach you know confidence in congruent decision making the majority of caregivers agreed that decision making on the care of the patient would be done through consultation with other family members and the doctor there was a general consensus that as caregivers they know the care recipients well and hence would be able to make decisions that were congruent and in keeping with the latters choices and in their best interest even without any prior exploration or discussion sociocultural factors cultural beliefs were commonly identified as one of the main reasons for not discussing further about advance care planning overwhelmingly caregivers reinforced the belief that acp should not be initiated as such discussions of endoflife issues were considered taboo and run counter to prevailing asian cultural values such as filial piety and respect for the elderly some caregivers cited superstitious beliefs surrounding such discussions for instance how such discussions were tantamount to bringing bad luck and cursing their loved ones taboo lah okay i think because of the asian culture taboo death is taboo to them no because we chinese ah dont want to mention all this the majority preferred to allow their spirituality and religious belief to determine how they would subsequently journey in life with their illness taking an active role in planning for future deterioration in their condition appears to be at odds with the beliefs and worldview of religious piety which emphasizes submitting to the sovereignty of the almighty i believe that my hands my life is in the hands of my god so whatever happen uh he will provide for for my safety and welfare the life is not mine the life i believe is given to me by the almighty inappropriate timing of discussion an indirect corollary of the patient caregiver and sociocultural barriers described above is an inertia among caregivers against initiating acp discussions in the mild stage of dementia despite acknowledging the benefits of conducting these discussions prior to loss of cognitive functioning thus some caregivers alluded to this inappropriate timing of the discussion by rationalizing that the patients condition had not yet sufficiently deteriorated to such an extent as to warrant discussion of such serious and taboo matters we feel that our dads condition our parents condition whatever illness they have or whatever is still within control it hasnt reached a stage where it has to be uh has to be seriously discussed discussion differential perceptions of acp among pwd and caregivers our study adds to the growing body of evidence on acp discussions in dementia by reporting the differential perceptions of acp among patientcaregiver dyads of predominantly chinese ethnicity in an asian setting and the somewhat unexpected positive response towards acp by pwd contrary to most published western literature of increased receptivity to acp in both patients and caregivers 4344 the proportion of caregivers in our study who were keen on further acp discussions declined although the proportion who agreed to the importance of acp remained constant after acp counseling this contrasted with the patient group where there was a postcounseling increase in the proportion who was keen to have further acp discussions despite a reduction in those who deemed this important the observed postcounseling increase in the proportion who acknowledged barriers to communication in both groups could be attributable to increased awareness of perceived barriers as a result of acp counseling interestingly this was associated with a differential response to willingness for further discussion being increased amongst pwd and decreased among caregivers the differential perceptions may pose a barrier to continued acp discussions given that acp is a dynamic process that involves engagement of conversations in an iterative manner reflections and values clarification in this study persons with dementia reported positive responses towards acp where the majority found it useful in understanding the complications of an illness and exploring preferences for future treatment and were willing to have continued acp discussions this finding is in contrast to a study by dening et al 45 where pwd did not perceive the potential value of acp and to an integrative literature review by geshell et al 46 where many pwd held a neutral to negative view towards acp engagement in acp discussions can be cognitively demanding for pwd and they may have difficulties in understanding how articulation of healthcare preferences may influence care later nevertheless the keenness and readiness for acp by pwd may represent the precontemplation stage of the acp process and the first step towards the contemplation of treatment wishes and values in the event of decisional incapacity meaningful participation in acp by pwd can be supported and facilitated by utilizing decisionmaking tools or aids to frame the conversations in a structured and intelligible manner 47 48 49 barriers to initiation of acp 421 patientrelated barriers overall the results of this study affirm the linking of barriers to the steps of contemplation and discussion in the acp process this is congruent with the conceptual model of schickedanz et al 22 who demonstrated the selfidentified barriers to acp the reported patientrelated barriers in this study are consistent with other research studies 5051 examining the factors that hinder initiation of acp in pwd or early cognitive impairment the transference of decision making to other family members may be viewed as the proper social order to maintain the familism and conduct of family duties and a showcase of filial piety in asian culture 37 this inevitably propagates the proclivity of not planning for the future should the patients health status deteriorate to the point of incapacity the cognitive deficits experienced by pwd may preclude them from fully participating in acp conversations due to the lack of understanding of what acp entails and lack of appreciation of the future endoflife care as reported in this study nevertheless people with cognitive impairment can still participate meaningfully in acp conversations with the listener being vigilant to discern their preferences and values 52 caregiverrelated barriers we expanded on the conceptual model of the process of acp 22 by including insights from mixed methods analysis on caregiverrelated barriers which feature prominently in our study caregivers were more likely to acknowledge barriers to acp than patients with mild dementia although caregivers were also more likely to find acp useful in understanding the complications of illness they revealed their discomfort in broaching endoflife issues due to the perceived negative impact of such discussions on patients which is consistent with past studies 5354 a unique finding in our study was the perceived congruence in future care decisions by the caregivers this may help explain the reluctance among caregivers to engage in further acp discussion postcounseling such perceptions may result in avoidance behavior to engage in acp as caregivers attempt to navigate through existential tensions confronted during discussions on endoflife care as dementia progresses to the terminal stage in their loved ones 19 furthermore incongruent endoflife care preferences have been reported between patients family and physicians 5556 a crosssectional study in the uk 57 reported less agreement for future hypothetical health states between pwd and their family caregivers in the choice of endoflife treatment batteux ferguson and tunney 58 provided further evidence of surrogate inaccuracy by reporting discrepancies between a surrogates choices and those made by cognitively intact care recipients further studies are needed to ascertain whether the confidence of caregivers in congruent decision making is borne out in actual practice our results reinforce the central role of sociocultural factors in influencing acp discussions consistent with the esteemed values of the asian culture the acceptance of decision making by the caregiver on behalf of the infirmed parent is an unspoken responsibility akin to an act of filial piety there seems to be an implicit understanding that caregivers will know the preferences and wishes of pwd though no prior discussions had occurred our findings concur with two local studies that highlight the influence of the family unit in the decisionmaking process 5459 thus reinforcing the prominence of a collectivistic culture among asians 6061 a familycentered acp model involving pwd and their caregivers also has been reported to be suitable for asian countries with a predominantly chinese culture where relational autonomy often times supersedes personal autonomy 62 in a collectivist society with pervasive cultural differences such as singapore culture has a direct influence on communication 63 topics such as death end of life and sickness are not explicitly or frequently discussed thus it is important to maintain sensitivity towards such topics when discussed our study highlighted the contribution of cultural diversity as a communication barrier to acp such as the twin taboo of dementia and acp superstitious beliefs surrounding acp discussions and spiritual and religious beliefs a persons culture shapes the way they think and how they make meaning out of illness suffering and dying 64 hence culture inevitably plays an important role in influencing decision making towards the end of life 6566 there have been calls to develop a culturally tailored acp to meet the needs of culturally diverse populations 3767 timing of acp initiation and discussion in our study the patient caregiver and sociocultural barriers combined to create a negative perception especially among caregivers regarding the inappropriate timing of initiating acp discussions at earlier stages of dementia patientcaregiver dyads viewed good health and early stage of dementia as indicators to delay acp discussions this is tantamount to a retrograde shift from the contemplationdiscussion phase to the precontemplation phase despite scientific publications acknowledging the timesensitive need for acp in pwd 4668 there is currently no consensus on the optimal timing to initiate acp discussions during the course of dementia 28 compared to the situation in cancer patients where acp discussions are initiated when there are clear demarcations between curative and palliative treatment persons with dementia go through a less predictable disease course 14 as a result acp discussions can only be initiated when patients and caregivers are ready to be engaged in such sensitive dialogues hence emphasizing the need to tailor such discussions to individual readiness and openness nevertheless beginning acp early in the course of dementia can provide opportunities for ongoing and gradual conversations to slowly engage patients and caregivers in participating in the planning process 69 a possible complex array of factors need to be considered to determine the optimal timing of acp discussion in dementia such as acceptance of the diagnosis of dementia understanding of the trajectory of illness and future cognitive decline decisionmaking capacity readiness to engage in emotionally laden conversations and the ability to decide on preferences based on future clinical scenarios hence further research is required to determine the optimal timing for acp discussions in pwd and concurrently examine the factors that contribute to initiation of acp along the dementia trajectory current state and progress of acp in singapore there was an increase in the number of completed acp documents in singapore over the last decade from 3 in 2011 to about 14000 in 2018 38 from a hospitalcentric practice perspective initiation of acp discussions are typically among individuals with lifelimiting illnesses such as advanced cancer or terminal illness but acp discussions are now being moved upstream to the primary care setting for individuals with chronic diseases and who are healthier there are three tiers of acp discussion promulgated in singapore 70 depending on the individuals medical condition general acp for relatively well and healthy adults diseasespecific acp for patients with progressive lifelimiting illnesses with frequent complications and a preferred plan of care for patients with advanced illness with a prognosis of less than one year diseasespecific acp forms meant for endstage renal failure advanced heart failure and chronic lung disease were developed but what is notably absent currently is diseasespecific acp forms for dementia given singapores collectivist society and multicultural communities local research in the conduct of acp discussions among pwd is surprisingly still lacking advance care planning has gained wide local recognition as one component of multifaceted dementia care it does not encompass solely the completion of advance directives but more importantly the initiation of discussions and contemplation of sensitive topics that people tend to avoid our study attempts to address the dearth of local research in acp for pwd and in explicating our research findings we hope to advocate for progress in initiation and documentation of acp discussions for pwd through strategies that consider the patientcaregiver dyads perception in order to overcome barriers to acp limitations and strengths of the study there were notable limitations in our study the study population was not a true representative of the diverse ethnic variation in singapore since there were no malays or eurasians recruited even among recruited subjects our englishspeaking sample may be reflective of a more privileged group who may not represent the general population nonetheless the more reserved views to acp reported in this study are consistent with the prevailing sociocultural values an additional challenge for the analyses in the current study was the semantic inaccuracies amongst our local elderly english language speakers as most singaporeans express themselves using a combination of english and their mother tongue during casual conversation much effort had to be made to discern the underlying themes from the recorded conversations however we believe this may also contribute to the richness and diversity of ideas in the context of a multicultural society this study also highlighted the unique influence of sociocultural factors above and beyond the identified caregiver and patientrelated barriers which together contrived to yield a timing barrier in the context of acp discussions in mild dementia an added strength of the study was the complementarities afforded by using a mixedmethods analysis which allowed for a broader and more comprehensive explication of this phenomenon to crossvalidate and complement individual findings conclusions advance care planning provides an opportunity for pwd to articulate their preferences and values while still retaining decisionmaking capacity but not without confronting barriers to contemplation or initiation of such emotionally sensitive conversations our study highlights the central roles that family and culture play in acp discussions in our asian society in tandem with patient and caregiver barriers to effective acp communication differential perception towards acp may hinder pwd and caregivers from taking the first step towards initiating intimate conversations on future care future studies are needed to explore ethnic differences in the sociocultural barriers to acp discussion and their influence on the optimal timing of initiating acp discussions more importantly studies are needed to understand how the impact of patient caregiver sociocultural and timing barriers can be mitigated in order for acp discussions to move beyond the contemplation stage to the necessary discussion phase among both patients and their caregivers data availability statement the data presented in this study are available on request from the corresponding author author contributions na and mc conceptualized designed and planned the study pa wsl and msc assisted with recruitment of participants and assisted in the collection and analysis of quantitative data ewhp and vd provided input on the qualitative analysis of the data all authors contributed to the writing of the manuscript all authors have read and agreed to the published version of the manuscript funding this research received no external funding institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki and approved by the institutional review board of the national healthcare group informed consent statement informed consent was obtained from all subjects involved in the study

a parallel mixedmethods study on 20 patientcaregiver dyads in an asian population was conducted to explore the differential perceptions and barriers to acp in dementia we recruited englishspeaking patients with mild dementia and their caregivers a trained acp facilitator conducted acp counseling patientcaregiver dyads completed prepost surveys and participated in postcounseling qualitative interviews we used mixedmethods analysis to corroborate the quantitative and qualitative data differential perceptions of acp were reported among dyads with caregivers less inclined for further acp discussions postacp counseling caregivers were significantly more likely to acknowledge barriers to acp discussions than patients 579 versus 105 p 0005 thematic analysis of the interview transcripts revealed four themes around barriers to acp patientrelated factors transference of decision making poor cognition and lack of understanding and disinclination to plan for the future caregiverrelated factors perceived negative impact on the patient caregiver discomfort and confidence in congruent decision making sociocultural factors taboos superstitions and religious beliefs and the inappropriate timing of discussions in a collectivist asian culture sociocultural factors pose important barriers and a familycentric approach to initiation of acp may be the first step towards engagement in the acp process for acp in dementia to be effective for patients and caregivers these discussions should be culturally tailored and address patient caregiver sociocultural and timing barriers

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introduction as a part of the essence of the traditional confucian culture face not only has its rich connotation penetrated into all levels of social life in china since ancient times but also reflects the social psychology with deep images in chinese culture mr lu xun pointed out in his article speak of face that face is the guiding principle of the chinese spirit famous modern scholar mr lin yutang once pointed out in the chinese that face is abstract and unpredictable but it is the most delicate standard for chinese people to regulate social interaction ms hu xianjin an early anthropologist studying in the united states pointed out in her book on the concept of face in china that face represents a reputation that is widely valued in china rising step by step in the course of life the reputation gained through success and boasting is also the reputation accumulated through personal efforts or the ability to operate which is called reputation in the eyes of westerners the concept of face emphasizes a personal centeredness which emphasizes the independent development of individuals and promotes the achievement of personal development famous american sociologist goffman proposed the famous theory of face behavior which comprehensively discusses the concept of face that is face is a ritualized social interaction behavior 12 in other words the interactive behavior between social individuals needs to rely on certain norms to operate normally face represents individual behavior that conforms to specific social norms as well as the social support that individuals receive through their understanding and application of the concept of face face culture is a common phenomenon in chinese and western cultures and it is also a specific reflection of specific cultural values in language under the background of cultural diversity as a complex social psychology it plays an important role that cannot be ignored in crosscultural communication chinese people equate face with personal dignity believing that face is recognition and respect for oneself and we must not lose face in any way china is a society where human relationships are quite prevalent only when you give others face can others give you face therefore the concept of face in chinese people is like an invisible face and face is face in western countries face and politeness are linked together american anthropologists brown and levinson define face as a personal image that every member of society wants to earn for themselves in the public the concept of face is an important component of cultural differences between china and the west 34 face theory american sociologist goffman proposed the issue of face from a sociological perspective believing that face is the positive social value that people earn for themselves in social interactions and the selfimage that individuals express according to the standards of social approval based on this british anthropologists p brown and s levinson further studied the issue of face and concluded that face is a personal image that every member of society intends to earn for themselves in the public through communication with others this image can be damaged maintained or enhanced face has characteristics that span different cultures and is universal brown and levinson set that people participating in social communication activities are typical people who are rational people with a need for face who hope to gain face in social communication and have normal communication skills the face of typical people is the personal image presented in social communication brown and levinson believe that every typical person has two types of face positive face and negative face positive face refers to the desire of each member of society to receive praise and affirmation from others for their wishes while negative face refers to the individuals desire to have their behavior free from interference or obstruction enjoy autonomy and freedom and not want to be imposed in social communication people often lose face due to an action sentence etc therefore in social communication we should respect each others positive face while also taking care of negative face so as not to make both parties feel embarrassed this is the face preservation theory established by brown and levinson based on western culture brown and levinson believe that every conversation is a face damaging behavior where both the positive and negative faces of the speaker are threatened the damage may be to the face of both the speaker and the recipient it can be either a positive face or a negative face brown and levinson classify face threatening behavior into four categories language behaviors that lead to a loss of positive face for the listener such as opposition argument criticism contempt mockery complaint rebuke insult suspicion etc behaviors that cause negative face damage to the listener such as commands warnings reminders requests and threats to express strong personal opinions behaviors that cause the speakers positive face to be damaged such as apologizing thanking accepting compliments etc behaviors that cause negative face damage to the speaker including expressing gratitude accepting proposals and giving promises cross cultural communication cross cultural communication refers to oral communication conducted by communicators from different cultural backgrounds using the same language in a specific communication scenario which includes three meanings 5 both parties in communication must come from different cultural backgrounds cultural background differences are a broad concept that refers not only to differences between different cultural circles but also to differences between subcultures within the same cultural circle based on the analysis of current crosscultural communication practices communication errors caused by cultural background differences are most likely to cause conflicts among chinese people in their interactions with people from european and american countries although there are cultural differences in chinas interactions with countries in the asian region including japan south korea and some southeast asian countries they usually do not create significant obstacles because china and these countries belong to the eastern cultural circle and there are many similarities in cultural orientation and communication norms between them both parties in communication must use the same language for communication if one party uses one language and the other party uses another language communication cannot proceed since both parties in communication come from different cultural backgrounds and use the same language the language used for communication may be the mother tongue for one party and the second language for the other party but there is also a situation where both parties in communication are in the second language for example if chinese people communicate with japan they cannot speak japanese and japanese people cannot speak chinese however if both parties are familiar with english they will choose to communicate in english both parties in communication focus on realtime oral communication there are various ways of crosscultural communication which can be verbal communication or nonverbal communication including goods pictorials physical objects images and performances to other materialized forms of symbols it can be onsite twoway communication or oneway communication through media including television radio newspapers and advertisements it can be oral communication or written communication including letters and official documents from the perspective of foreign language teaching crosscultural communication mainly refers to realtime oral communication that is facetoface conversations between two parties the problems faced in crosscultural communication cross cultural communication faces many new problems 6 firstly cultural cognitive stereotypes due to the inherent ideology cultural background and cognitive environment of different ethnic or national populations in different cultural backgrounds they have formed an inherent understanding and perspective on the civilization and culture of other countries which affects crosscultural communication the second is the cultural barrier affected by the specific natural environment of different countries and ethnic groups as well as unique political systems legal systems religious beliefs ideologies customs and cultural traditions people sometimes use their own culture as a standard and reference to judge other cultural circles causing resistance to understanding and identification the third is the solidification of cultural transmission methods currently cultural products still need to further meet the cultural information needs of enhancing international discourse power fourthly the mechanism for cultural exchange and cooperation needs to be improved from a domestic perspective cultural exchange and cooperation mechanisms in various regions need to be improved and encouraging policies and measures for folk cultural exchange need to be strengthened from a foreign perspective there are significant differences in cultural foundations among different countries which to some extent affects the development of crosscultural exchanges and cooperation cross cultural communication strategies guided by the face concept in china and the west the concept of face in chinese and western cultures has different connotations due to their different cultures in interpersonal communication the concept of face is often expressed through verbal forms such as addressing each other expressing gratitude disagreeing and receiving praise in crosscultural communication neglecting the use of face preserving strategies may lead to conflicts or contradictions in order to smoothly carry out crosscultural communication and achieve the goal of harmonious communication appropriate strategies are particularly important pay attention to historical and cultural differences the long history of chinas agricultural society has emphasized collective cooperation and interdependence among individuals the values born in this historical context are the values of collectivism emphasizing the function and strength of the collective emphasizing the sociality of humans the unity of humans and society and the individual being subject to the collective at the same time the confucian ethical ideology that emerged under the cultural conditions of agricultural society also emphasizes harmony and unity as well as the unity of individuals collectives and society 7 therefore the face of chinese people is based on social group awareness emphasizing recognition of their social status and reputation as well as recognition of their needs by society the history of western countries is a history of ethnic migration in the process of continuous migration and exploration different ethnic groups have merged blood relationships have become increasingly distant and the manifestation of selfworth between people has become increasingly evident in this historical context individualistic values that highlight and emphasize oneself emerged the formation of modern western capitalist private economy further emphasized individualism and selfawareness therefore the face of westerners emphasizes self satisfaction and respect for personal wishes rights and privacy which is the defense of face issn 26165783 vol6 issue 20 132136 doi 1025236ajhss2023062022 published by francis academic press uk 135 pay attention to differences in personality and thinking compared to westerners chinese people have a more introverted personality without the publicity and directness of westerners when their own interests are threatened they always do not speak out directly but adopt a humble approach it is better to sacrifice ones own interests than to allow others to be praised and satisfied in order to show ones politeness and comity in exchange for being recognized by the group as a face westerners have an extroverted personality and they will directly fight for their rights so that their rights are not affected thus defending their negative face chinese peoples thinking belongs to the circular type of thinking and people are accustomed to pursuing harmony and dialectics from the whole to the part their thinking is characterized by generalization and ambiguity and more emphasis is placed on etiquette when there is a conflict between the cooperative principle and the politeness principle in verbal communication the politeness principle will be chosen to try not to harm the other partys face 8 westerners belong to the linear mindset accustomed to moving from parts to the whole emphasizing logical analysis and being good at solving specific problems better when there is a conflict between the principle of cooperation and the principle of politeness they will choose the principle of cooperation and convey sufficient information to the other party in the best way so that their ideas can be respected by others in order to save their positive face strengthen the cultivation of cultural empathy ability cultural empathy refers to the psychological experience emotional displacement and cognitive transformation that the communicative subject undergoes in crosscultural communication to ensure smooth communication between different cultures that is consciously transcending the psychological constraints of the national language and culture and standing in another cultural mode for thinking due to the existence of different cultures and ethnicities between different countries and regions it is necessary to think from different ways of thinking about ethnic cultures in the process of cultivating crosscultural communication skills communicators find a fit between different cultures integrate multiple cultures in the context of globalization and conduct cultural analysis from multiple perspectives in order to truly adapt to the development of the times 9 cultural empathy is a subjective consciousness and only by consciously learning and understanding culture from the perspective of subjective consciousness can communicators free themselves from the constraints of local culture at both the psychological and emotional levels thereby achieving the goal of harmonious coexistence with people in different cultural backgrounds conclusions cross cultural communication is a type of communication behavior which can be interpersonal communication or communication between individuals and groups in terms of types of communication the continuous development of economic globalization and information networking has made globalization an irreversible trend people from different regions and cultural backgrounds are increasingly forming a stance of survival as world citizens and crosscultural communication ability has become a basic survival skill for people cross cultural communication is the communication that occurs between people from different cultural backgrounds and close crosscultural communication is an important feature of todays world the face culture as a common component of chinese and western culture has specific differences due to the different cultural backgrounds between the two overall the western face culture that emphasizes the maintenance of negative face and the chinese face culture that emphasizes the maintenance of positive face have distinct characteristics which are important factors affecting the normal crosscultural communication between china and the west different cultural backgrounds lead to certain differences in peoples lifestyles value orientations and ways of thinking which to some extent hinder the normal progress of crosscultural communication therefore in crosscultural communication in order to minimize cultural conflicts and communication barriers caused by differences in face saving cultures between china and the west appropriate face saving cultural strategies should be adopted to ensure the normal progress of crosscultural communication

cross cultural communication is the communication that occurs between people from different cultural backgrounds and crosscultural communication ability has become a fundamental survival skill for people face culture is a common phenomenon in chinese and western cultures and it is also a specific reflection of specific cultural values in language under the background of cultural diversity as a complex social psychology it plays an important role that cannot be ignored in crosscultural communication with the rapid development of economic globalization communication between countries continues to deepen and crosscultural communication also becomes frequent in order to smoothly carry out crosscultural communication and achieve the goal of harmonious communication appropriate strategies are particularly important this article is based on the face theory and proposes crosscultural communication strategies guided by the face view of china and the west emphasizing historical and cultural differences emphasizing personality and thinking differences and strengthening the cultivation of cultural empathy ability

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in the united states had alzheimers disease in 2021 and this number is projected to reach 88 million by 2050 the american academy of neurology estimated that about 8 of people aged 6569 have a mild cognitive impairment about 15 of those aged 7579 about 25 of those aged 8084 and about 37 of people 85 years of age and older cognitive impairment is associated with functional impairment in daily life independent of the effects of depression fatigue and motor disability deficits in cognitive ability can impair daytoday decision making motivation and new learning sufficient to affect selfcare in both higherorder and basic activities of daily living as well as to affect capacity for gainful employment and promote the transition to permanent disability status a recent us study indicated that nearly 70 of people with cognitive impairment developed physical disability over 10 years of followup which may be a further cause of impairment in daily living with an increasingly aging society cognitive impairment and its associated care needs are likely to become a greater public health problem currently informal care is the primary source of care for cognitively impaired americans accounting for 83 of all care however this form of care is often not available for those who live alone as people living alone experience greater isolation associated with a diminished social network of available family or friend caregivers older adults living alone have significantly more unmet needs in the domains of housework and community living and are at greater risks of adverse health outcomes compared with those living with others given that a considerable proportion of the older adults lives alone meeting the needs of cognitively impaired us older adults living alone is an important issue gender and racial disparities in the prevalence of cognitive impairment and corresponding physical disabilities and social support were widely documented for instance mexican american older adults who live alone experience dual risks of both greater cognitive impairment and receiving low support from others when compared to mexican american older adults who live with others compared to white americans black and hispanic americans were reported to have a higher prevalence of dementia and less access to health services females were more likely to experience racialethnic differences in physical disabilities and corresponding support among older adults living alone with cognitive impairment than males recent studies also estimated the time trend of gender and racial ethnic disparities on the prevalence of cognitive impairment however to the best of our knowledge the time trend in physical disabilities and social support has not been quantified over time this study aimed to examine temporal trends in the prevalence of physical disability and social support among older adults living alone with cognitive impairment from 2000 to 2018 in the united states with a focus on gender and racial ethnic disparities such evidence might be expected to help address the concerns of cognitively impaired older adults living alone via targeting vulnerable subgroups and supporting the development of interventions and public policies to eliminate inequalities we hypothesized that the prevalence of physical disability would increase over time the probability of receiving no social support would decrease over time and gender and racialethnic disparities may exist in the above trends method data source and participants this study used data from the health and retirement survey a nationally representative and biennial study of us adults aged 50 years or older each participant completed a standardized questionnaire facetoface or via internettelephone assessments described elsewhere data included sociodemographic characteristics health information and testing of cognitive performance for those able to perform the tests or proxyreported information on cognitive ability for those unable to do the tests as well as those unwilling to answer for themselves we utilized 10 waves of hrs data spanning 2000 through 2018 eligible people were those aged ≥65 having cognitive impairment and living alone the data are publicly available the use of secondary deidentified data makes this study exempt from institutional review board review this study follows the strengthening the reporting of observational studies in epidemiology reporting guideline outcome and measures individuals with cognitive impairment considering the potential for reversion of cognitive impairment cognitive impairment was judged for each wave and was identified by using a validated algorithm designed for hrsbased studies of dementia the algorithm incorporates performance scores of telephone interview for cognitive status and scores of proxyreported information on cognitive impairment and functional limitations the tics is a 27point cognitive scale that included an immediate and delayed 10noun free recall test a serial 7s subtraction test and a backwardscountfrom20 test the proxy index is an 11point scale covering the participants memory limitations in 5 instrumental activities of daily living and difficulty completing the interview because of a cognitive limitation participants were classified as having probable dementia if they scored 6 or lower on the tics or scored 6 or more on the proxy index participants with cognitive impairment no dementia were those who scored 711 on the tics or 35 on the proxy index full details about the tics and proxy assessment can be found elsewhere physical disability includes disability identified from basic activities of daily living and iadls participants with badl disability were defined as those who reported difficulty in 1 or more of 6 badl items participants with iadl disability were defined as those who reported difficulty in 1 or more of 5 iadl items we distinguished badl disability from iadl disability because disability in activities is developed in a progressive manner associated with cognitive decline badls are related to basic activities that allow people to care for themselves while iadls are related to more complex activities that allow an individual to live independently in a community the distinction between badl and iadl disability can inform customized interventions to meet the needs of patients with physical disability social support was assessed by questionnaire items corresponding to the 11 badlsiadls listed above for each item respondents were asked if they received help from others to gain insight into the social support received by respondents we adopted 2 concepts used in the evaluation of health care utilization namely a contact process and a frequency process in this study to examine any unmet needs for social support the contact process corresponded to 2 binary variables indicating whether respondents with physical disability received no badl or no iadl support we refer to someone as badlunsupported if they report some badl disability but received no support for badls and iadlunsupported likewise the frequency process corresponds to a counting variable indicating the number of unmet social support needs assessed by calculating the difference between the number of badl or iadl difficulties and the number of badlsiadls for which some support was provided statistical analysis to describe the baseline characteristics categorical variables were reported as number and continuous variables were reported as mean for binary outcomes to estimate linear trends over time we fitted logistic regression models by including year as the key predictor controlling for age gender racialethnic status whether a proxy response was required and dementia status logit α β year γ 1 x 1 γ n x n ε where logit is the log odds of a binary outcome year is a continuous variable x 1 x n are the covariates controlled for the odds ratio associated with year represents for example the change in the odds of badl disability per year or 1 indicates an increasing quantity across the study period and or 1 is the converse to estimate gender disparities in trends we fitted a similar model but added the interaction between gender and year we tested for racialethnic disparity similarly logit α β year θ year ×gender γ 1 x 1 γ n x n ε equivalent poisson regressions were conducted for integer outcomes but with the outcome variable as log where λ is the number of occurrences survey weights were used to account for sampling design and study attrition the weight values were provided directly in the hrs data sets details of how the weights were calculated can be found elsewhere all analyses were completed using r version 360 we report 2tailed p values and 95 confidence intervals throughout p 05 was considered to be statistically significant results basic description including badliadl impairment and support from the hrs 20002018 a total of 20 070 eligible respondents aged 65 with cognitive impairment who lived alone were included in this study including 12 466 respondents having probable cind and 9 190 respondents having probable dementia table 1 summarizes their basic characteristics participants mean age was 809 years and the majority were women and white overall 478 of eligible respondents reported some badl disability of whom 329 received no badl support among those who received badl support the mean number of unmet badl support needs was 058 overall 49 of the eligible respondents reported some iadl disability of whom 121 received no iadl support among those who received iadl support the mean number of unmet iadl support needs was 098 gender or racialethnic differences in badliadl impairment females had a higher likelihood of reporting badl disability and iadl disability compared with males table 2 badliadl impairment over time with gender or racialethnic differences from 2000 to 2018 no significant linear trends were found in the overall prevalence of badl disability or iadl disability no gender disparities were found for these trends compared with white respondents hispanic and black respondents had relatively increasing trends in badl disability hispanic respondents also had a relatively increasing trend in iadl disability gender or racialethnic differences in badliadl support among those who reported disability females were less likely to be badlunsupported and iadlunsupported compared with males hispanic and black respondents were less likely to be badlunsupported compared with white respondents and hispanic respondents were also less likely to be iadlunsupported among those who reported disability and receipt of badl iadl support no gender difference was found in the number of unmet badl support needs or unmet iadl support needs hispanic and black respondents had no difference in the number of unmet badl support needs but had significantly fewer unmet iadl support needs compared to white respondents badliadl support over time with gender or racialethnic differences the proportion of people unsupported for badl needs decreased significantly over time but the proportion of people unsupported for iadl needs increased no significant trend was found in the number of unmet badl support needs among those receiving badl support but among those receiving iadl support the number of unmet iadl support needs increased over time no gender disparities were found for these trends no racialethnic disparities were found in the trends for receipt of badl or iadl support except that black respondents had a relatively increasing trend of being badlunsupported and hispanic and black respondents had a relatively increasing trend in the number of unmet badl needs compared to the corresponding trends in white respondents note however the overall differences discussed above the relatively worse trend of a lesser reduction in support for badl over time among black respondents relative to white respondents was on the background of a better situation overall which is compatible with a slight narrowing of racialethnic disparity over time for the number of unsupported badl needs there was greater deterioration over time among hispanic black respondents than white respondents for the number of iadl needs there was an increase across racialethnic groups but a better situation for blackhispanic respondents independent of time subgroup by cognitive impairment no dementia and dementia subgroup analyses indicated that the above racialethnic disparities in the trend of reporting badl disability being badlunsupported and the number of unmet badl support needs were mainly identified among those with dementia rather than cind while iadlrelated disparities were identified among both people with cind and dementia unmet support needs by items of adl and iadl the proportions of respondents with unmet support needs are reported for each badliadl item in supplementary figures 123456 compared to males females reported more unmet support needs for toileting walking preparing a hot meal and shopping for groceries while compared to females males had more unmet support needs for dressing compared to white and black respondents 4125 notes badl basic activity of daily living cind cognitive impairment no dementia iadl instrumental activity of daily living trends were measured by the adjusted odds ratio and its 95 confidence interval which was obtained from the coefficient of the year predictor in the logistic regression controlling for age gender raceethnicity whether a proxy response was required and dementia status or 1 indicates an increasing trend in the quantity across the study years and or 1 indicates a decreasing trend results were shown in boldface if their corresponding pvalue 005 table 2 continued hispanic people reported more unmet needs for getting in out of bed dressing and eating compared to white and hispanic respondents black people reported more unmet needs for dressing toileting walking preparing a hot meal and shopping for groceries compared to black and hispanic respondents white people reported more unmet needs for preparing a hot meal taking medications making phone calls and shopping for groceries people with cind had more unmet badl support needs than unmet iadl support needs while people with dementia had more unmet iadl support needs than unmet badl support needs discussion statement of principal findings this study assessed trends in badl and iadl disability and social support among cognitively impaired us older adults living alone and the influence of gender and racialethnic disparities overall between 2000 and 2018 the proportion of people who were badlunsupported decreased while those who were iadlunsupported increased females had a higher likelihood of reporting badl and iadl disability compared to males hispanic and black respondents had a higher likelihood of reporting badl and iadl disability compared to white respondents among those who reported badl or iadl disability female hispanic and black respondents were more likely to be in receipt of badl or iadl support among those receiving badl or iadl support there were no gender disparities in the number of unmet badl or iadl support needs and hispanic and black respondents had a lower number of unmet iadl support needs compared to white respondents over time fewer people with badl disability reported being badlunsupported but more respondents with iadl disability reported being iadlunsupported and among those who did receive iadl support the number of unmet iadl support needs increased over time there were no gender disparities in the trends in proportion of being badlor iadlunsupported or in number of unmet badl or iadl support needs overall improvements in badl support were seen over time but less so in black respondents the number of unmet badl needs increased more in black and hispanic respondents over time relative to white respondents unmet support needs by specific badliadl items were also reported interpretation our study identified some gender disparities including that females had a higher likelihood of suffering badl and iadl disability compared to males the results are consistent with another recent study that showed females were more likely to suffer from impairment in badls caused by cognitive impairment than males nevertheless females were more likely to receive badl or iadl support this is consistent with other findings from the united states and other countries which indicated that females are more likely to receive social support than males we also found that among 2455 year × raceethnicity 105 099 1 1035 notes badl basic activity of daily living cind cognitive impairment no dementia iadl instrumental activity of daily living trends were measured by the adjusted relative risk and its 95 confidence interval which was obtained from the coefficient of the year predictor in the poisson regression controlling for age gender raceethnicity whether a proxy response was required and dementia status rr 1 indicates an increasing trend in the number of unmet badl or iadl support needs across the study years and rr 1 indicates a decreasing trend results were shown in boldface if their corresponding pvalue 005 those receiving badliadl support there were no gender disparities in the number of unmet badliadl support needs the above findings indicated that the gender disparity may be a result of difficulties in a contact rather than a frequency process possible explanations might be that females are on average more active in neighborhood social networks and are more likely to ask for help or to contact other people when in need a customized intervention aiming at the contact process may be more effective in eliminating this gender disparity we identified racialethnic disparities in the prevalence of badl and iadl disability as well as the provision of corresponding social support black and hispanic respondents were more likely to suffer from badliadl disability than their white counterparts this finding is in accordance with prior studies conducted in the united states that found black and hispanic people were at greater risk for dementia and functional disability however compared to white people black and hispanic people were also more likely to receive badl or iadl support and had a lower number of unmet iadl needs racialethnic disparities were also identified in the time trends in the prevalence of badl disability and corresponding receipt of badl support given the baseline higher probability of reporting badl disability among hispanic and black respondents than white the relatively increasing trend identified in the prevalence of badl disability among hispanic and black than white respondents revealed that an increasing number of hispanic and black respondents reported badl disability over time compared to the corresponding trends in white respondents we also identified a relatively increasing trend of being badlunsupported among black respondents but no such difference was identified among hispanic respondents given the baseline difference of a lower likelihood of being badlunsupported among hispanic and black communities than white these differences in the time trends of being badlunsupported are compatible with some narrowing of disparity over time we display these trends in supplementary figure 7 showing that they resulted from an improvement in the receipt of badl support among white and hispanic communities while there was almost no improvement among the black community similarly supplementary figure 8 indicates that the relatively increasing trend in the number of unmet badl support needs among hispanic and black respondents was primarily because that hispanic and black respondents have been facing increasing numbers of unmet badl support needs over time these findings indicate that from 2000 to 2018 ethnic minorities with cognitive impairment living alone had greater or unimproved unmet needs for badl support both in terms of a contact process and a frequency process a customized intervention targeting at the different processes for different racialethnic communities may be more effective in eliminating this disparity possible reasons for the change in the above racialethnic disparities could include the entanglement of potential risk factors protective factors and resilience among racialethnic groups ethnic minorities were more likely to be exposed to shows the estimated time trend in the number of unmet badl or iadl support needs trends were measured via the adjusted relative risk and its 95 ci which was obtained from the coefficient of the year predictor in the poisson regression controlling for age gender raceethnicity whether a proxy response was required and dementia status rr 1 indicates an increasing trend in the number of unmet badl or iadl support needs across the study years and rr 1 is the converse high occupational risks and thus had a higher probability of suffering disability in older age with informal care being the primary source of support for us older adults with cognitive impairment studies have found that people from ethnic minorities were more likely to devote time to informal care than those of white ethnicity according to a caregiving report in the united states caregivers of ethnic minorities report providing more hours of care on average to their older recipients than white caregivers and are more likely to provide 21 or more hours of care weekly extensive costs for longterm care have been a challenge to those in need to access to formal care medicaid programs in many states have expanded home care and shifted funds toward homeand communitybased services in recent decades which could also facilitate some ethnic minorities to benefit from this expansion however the shortages in the longterm care workforce may disproportionately allocate a limited workforce to those covered by private longterm care insurance where white americans may have some advantages in terms of affordability our subgroup analyses on cind and dementia indicated that these badlrelated racialethnic disparities mainly occurred in people with dementia but not those with cind this difference between people with dementia and those with cind is to some extent in keeping with recent research showing that caregivers for an adult aged ≥50 years with alzheimers disease are more likely to have difficulties assisting their recipients with badls than those who provide care to someone without alzheimers disease intervention programs could be targeted and used to narrow these racial ethnic disparities in the unmet badlrelated needs especially in vulnerable subgroups with dementia as for the receipt of iadl social support no corresponding gender or racialethnic disparities were found but more people with iadl disabilities faced unmet iadl support needs across the period 20002018 this was observed both in the contact process and the frequency process in particular there were indications that number of unmet iadl support needs has increased more sharply recent years further our subgroup analyses on cind and dementia indicated that among people with cind the above unmet iadl support manifested mostly in support frequency while among people with dementia the iadl needs were less well met both in terms of contact and frequency this highlights the potential necessity of customized interventions for people with cind and dementia separately we also found that unmet support needs exhibited obvious variation between gender raceethnicity and people with cind or dementia this variation might come from peoples personalities their acceptance of personal services and the type of service personnel in practice this variation suggests that it is necessary to provide targeted and personalized services for specific service objects for instance mobility equipment and devices tailored to individual needs and circumstances might substitute for human assistance and facilitate selfcare for some daily activities adequate provision of homeand communitybased services such as homevisit medical services selfhelp support groups and respite care could also reduce unmet needs among vulnerable subgroups with dementia furthermore the needs of people with cognitive impairment are complex and coordination between different agencies in the health and social care systems is not always efficient leading to inadequate measures of unmet need among this population therefore to ensure the integrity of services provided to people with cognitive impairment it is important to assess needs regularly and determine what types of services or combination of service types are required strength and limitations to our knowledge this is the first study to assess systematically the influence of gender and raceethnicity on disabilities relating to adl and social support for them among us older adults living alone with cognitive impairment using populationbased and nationally representative data one strength of our study is that we give separate attention to badl and iadl the former is related to basic activities and the latter is related to more complex activities another strength is that we divided the process of receiving social support into contact and frequency processes further we reported unmet support needs by individual badliadl items all of these contribute to our understanding of how any gender and racialethnic disparities may arise and provide detailed evidence to more nuanced and practical public health policy strategies a key study limitation is the lack of clinical diagnosis of cognitive impairment or dementia however prior validation studies showed at least 91 concordance for dementia when using algorithm adopted above compared with the detailed aging demographics and memory study clinical evaluation another limitation is an inevitable potential for bias resulting from selfreported and proxyreported outcomes of disability and social support as either might underor overestimate difficulty or support received however both measures have also been validated previously thirdly for our measure of unmet social support we used the difference between the number of badl or iadl difficulties and the number of items for which support was received however this may underestimate unmet needs as the underlying hypothesis for this measurement is that each item of support people received completely met their corresponding need fourthly some people who receive certain support might not suggest that they need such support thus when we explore the association between overall disability and overall social support it is possible that the disability items may not correspond with the support items this will also underestimate unmet needs one unanswered question is the interaction between gender and raceethnicity although this study identified a higher likelihood for hispanic and black people to receive badl or iadl support a recent study showed that black women were less likely to receive badliadl support than comparable white women whereas this difference in the outcome was not significant in men a future study is needed with a focus on the interaction between gender and raceethnicity conclusion among us older adults with cognitive impairment living alone although the overall prevalence of badl and iadl disability remained steady between 2000 and 2018 fewer people received iadl support and the extent of unmet iadl support needs increased over time gender disparities were seen in the prevalence of badl or iadl disability and lack of corresponding support while racialethnic disparities were seen both in the prevalence of reported badliadl disability and unmet needs for badliadl support some racialethnic disparities narrowed for example with unmet badl support needs worsening over time in minority ethnicity groups relative to the majority ethnic group but from a better baseline data such as these allow for identifying groups most in need and therefore the potential to target support interventions to have the greatest impact data availability data are publicly available and can be accessed in conflict of interest authors of this article have the following competing interests sc hz bru dw and xc declare no conflict of interest with this work rnc consults for campden instruments ltd and receives royalties from cambridge university press cambridge enterprise and routledge role of the fundersponsor the funder had no role in the design and conduct of the study collection management analysis and interpretation of the data preparation review or approval of the manuscript or decision to submit the manuscript for publication supplementary material supplementary data are available at innovation in aging online

background and objectives informal care is the primary source of support for older adults with cognitive impairment yet is less available to those who live alone we examined trends in the prevalence of physical disability and social support among older adults with cognitive impairment living alone in the united states

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book reviews bijdragen tot de taal landen volkenkunde 179 275309 characters the author also amassed 30 images of bong pai and sin ci containing his familial lineage while the author has put together the book in two years as said in the foreword the project actually started much earlier as a young teenager hongsienwhose family had then recently migrated from malang to amsterdamwas handed a piece of paper by his father kwee tat kien on it was their kwee family tree neatly typed by his grandfather kwee tjoen liat in 1956 the book also contains a wide selection of documentation ranging from deeds wedding announcements and citizenship certificates to media clips the latter contains flattering news such as the knighting of greatgreat grandfather kwee sik poo by the dutch government in 1911 but there are also less savory ones like a clip headlined the fugitive millionaire referring to maternal grandfather the tik gwan who fled to europe for tax evasion some are unintentionally interesting like one from the indische courant of june 4 1935 listing students from malangs ursulinen teacher training course including the authors aunt the list however showed that out of a class of 27 there were only three chinese names and one javanese namethe rest were all dutch surnames some of the chinese indonesian family history books that have come out in the netherlands vary in scope and tone not many authors have the writers flair of physician yap kioe bing who packed history suspense and melancholy into the compact biography of his father oei hong kians autobiography was more ambitious in scope and in parts read like an attempt at a historical novel patricia tjiookliem wrote her family history through the lens of her greatgrandfather and at the same time gave an overview of peranakan chinese life in semarang a major port and trading city since the early years of dutch presence in the indonesian archipelago tjiookliem is founder and chairperson of the chinese indonesian heritage center set up in 2011 with the support of the royal netherlands institute of southeast asian and caribbean studies an academically solid publication was a volume that looked into the kwee family of west java written by two historians with no family ties to their subjects finally a good overview is given by the compilation of 50 short family histories told through 50 photographs encompassing chinese indonesian experiences throughout the archipelago and beyond that in china the netherlands and suriname compared to the above publications kwee hong siens book should be viewed more as a workinprogress in the book he invites readers numerous times to send him more information it is difficult to gauge how many similar projects like kwee hongsiens have been done within family circles outside of the public eye there should be a way to make these projects accessible beydownloaded from brillcom 05072024 043732pm via open access this is an open access article distributed under the terms of the cc by 40 license ond the families as these works contain a wealth of information invaluable for future historical studies linawati sidarto independent journalist amsterdam the netherlands

online this is an open access article distributed under the terms of the cc by 40 license kwee hongsien history of the han kwee and the families from pasuruan and surabaya kortenhoef selfpublished 2022 364 pp no isbn and price paperback while chinese indonesians were an integral albeit small part of the dutch east indies community for centuries very little has been published in the netherlands about this migrant group in contrast to other communities originating from former dutch coloniesmoluccans indoeuropeans papuans surinamese to name a fewchinese indonesians have been practically invisible in dutch society thus although it is unusual to review a selfpublished family chronicle like the book of hongsien kwee there are a number of reasons why it is worth discussing the 364page book gives an overview of kwees heritage through three families whose forefathers emigrated from fujianlike most of the chinese who settled in southeast asiato java in the eighteenth century the kwees are from his fathers lineage while his paternal and maternal grandmothers are respectively descendants of the the and han families they settled in east java and some of them became prominent figures in their communities and in the sugar business around the turn of the twentieth century the dutch east indies was one of the worlds main sugar producers once readers can go beyond the books rather jumbled layoutkeeping in mind that it was published for the authors extended family instead of the general publicthey can delve into a treasure trove of information first of all the story of the kwees hans and thes reflects the history of the peranakan chinese who settled in java numbering in the hundreds of thousands by the early twentieth century the copious volume of imagesnot organized chronologicallyare a dizzying yet connecting thread of the families generational journeys through time and geography there are pages with photos of han family members with the royal family of solo next to images of the same hans clearly somewhere in the netherlands pp 100101 two adjacent pages can have blackandwhite family photos taken in east java in the middle of the twentieth century next to color photos taken more than half a century later with more generations posing in their home in the netherlands pp 262263 these pictures which include some grand family homes still standing today are witnesses of the cultural mix which is at the base of the peranakan community and the migration flow of some of them to the netherlands a country far away yet familiar to them due to centuries of colonialism hongsien kwee took the genealogy part of his book very seriously 26 pages were devoted to the kwee han and the family trees from their first arrival in java all the way until the current generation for those able to read chinese

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introduction the enormous extension of life is one of civilizations greatest accomplishments of the previous century however societal developments frequently result in new demands and difficulties although the number of years that a healthy person can expect to live has grown the sheer number of persons in their 60s and older particularly those in their 80s has increased people beyond the age of 50 were regarded as elderly in 1875 according to the friendly society act which became the default standard in britain no of a persons age sequestration could be acquired glascock and feinmans anthropological research helped to define three categories that interfere in the final stages of life providing a more detailed foundation for old age these factors which also include historical events changes in a persons role or identity and diminished functions all have a negative impact on ageing and increase pain when population ageing is discussed it is essentially an effort to show a shift in the age distribution of people toward old age it means that there are more elderly people than young people in the population a human is typically categorized as an elder when they reach the age of 65 though elders can also be early or late in life people between the ages of 65 and 74 are referred to as early elders while those over 75 are referred to as late elders around 727 million individuals worldwide are estimated to be 65 or older as of 2020 and that number is anticipated to treble to 15 billion by 2050 by 2050 this will have increased from the current 93 percent to 160 percent additionally every sixth individual will be 65 years of age or older by the year 2050 globally gender disparity demonstrates that women live longer than males as a result women make up 62 percent of all people over the age of 80 worldwide and account for 55 percent of all people over the age of 65 this proportion of women also climbs with age according to a un estimate 6 of the worlds elderly populationthose who are over 65 years oldlives in the asian region in pakistan there were 15 million persons over the age of 60 or 7 of the total population this number will rise by 712 to 40 million in the coming years increase in population especially among senior age groups also alludes to a decrease in independence ratio which might possibly cause pakistans economy to suffer in addition other issues such a lack of food resources access to healthcare and discrimination or prejudice add to the problem in pakistani culture a person is simply considered to be old when he reaches the age of 60 consideration of a person as old may be based on cultural norms biological strength or weakness associated with ageing and other factors source united nations department of economic and social affairs population division world population prospects 2019 online edition rev 1 both genders experience substantial adjustments in old age including shifts in societal responsibilities genderspecific expectations and status within the family gender variations can be seen in both biological structure and functions in humans the social structure of culture with its division of genderrelated duties society functions and social status appears to have had a greater influence on gender disparities in quality of life than biological differences though the degree of physical and mental functioning life expectancy and mortality life expectancy with disabilities the incidence of diseases and risk factors and life expectancy can all be used to assess the health of communities according to numerous studies pleis lethbridgeejku who andzunzunegui et al women spend more years of their lives with functional limitations even though they make up more than half of the worlds population and typically live longer than men additionally elderly women do much worse on most measures of subjective wellbeing and mental health when compared to males the present study was focused on exploring the health problems faced by older persons of sohan village and to figure out if there is any relationship between the gender distribution of older persons and their health profile materials and methods research methodology as present research is concerned descriptive research methodology was opted by the researchers this is to explain the actual situation of social support patterns available for older persons of sohan village this methodology leads to interview method to fulfill the requirements of study research tool a structured well organized interview schedule was developed with the help of existing body of knowledge which later improved after pretest research tool is consisted of five section which includes a socioeconomic and demographic backgrounds b food c health profile mapping d sociocultural and psychological profile and e membership status these sections further divided into 71 questions including single and multiple responses locale and time period locale for the present study was sohan village located in zone 4 of islamabad district physically it is situated near highway stop on express highway data collection was started in january2021 and completed during the month of april2021 sample sample for present research was calculated statistically population of sohan village according to the 2017 census of pakistan was 47510 and number of households were 7635 sample was calculated twice both on population and household and calculated sample was 97 with 95 level of significance 5 error margin and 67 response distribution data management after data collection initially date editing was done after that code plan was developed before to start making a data entry file in cspro data was entered in cspro and converted into spss for cleaning and analysis 2 shows that for the sake of health mapping three indicators are considered impairment routine health issues and chronic diseases impairment refers to the problem with body structure and in this consequent case it referred to visual hearing mental and physical impairment it can be observed that most ops were facing visual impairment that is 33 while 15 were having hearing issues 25 had physical problems and only 4 had a mental impairment it relates to the fact that the mind is the last one to stop working that too at very old age results and discussion health routine issues are the common problems of health people face in their daily routines which include temperature cough body aches joint pains stomach issues and bp these problems are so common specifically in old age that every second person is disposed to it the data showed that the mostly older persons had stomach and bp issues that is 40 while 35 had joint issues 28 persons had body aches 29 people had a cough and only 12 had a temperature with old age the bone becomes weak so it is very common to face body aches but due to change in diet and social pressures the problems of bp and stomach issue has left others behind in case of chronic diseases by which old persons were suffering included hypertension heart problems epilepsy diabetes arthritis asthma hepatitis bc and tb as given in table the mental health issues which were the most prominently present was hypertension with frequency of 24 20 had arthritis while 16 were having hearts issues 11 suffering with asthma 9 had diabetes 4 had tb and only 2 cases of hepatitis bc in reference to pakistan the aging population has been increasing with ratio of 460 in 1990 580 in 2000 and with this ratio of increase it was expected to increase by 600 in 2006 730 by 2025 and so 1240 by 2050 the measures taken have ensured prolonged life which was one of the main achievements of civilization it further increased healthy life expectancy even of the older person with their share aged 60 or above as well as 80 and above with a such massive ratio of older persons the diseases associated with them will also be numbered so more generations can be expected as unhealthy ultimately leading to result in an unproductive population therefore there is an urgent need to address this issue given the threat it poses to the economies of those nations where there is rapid population growth in a huge primarily unproductive sector as it also ultimately gives rise to costs for the need for social and medical services due to these changes aging societies around the world have challenges in preserving good health and a high standard of living as well as reducing the number of years with disabilities in old age the necessity to solve these issues should stem from the humanitarian values that are ingrained in democratic nations cultures and are eloquently stated in the us declaration of independence we hold these truths to be selfevident that all men are created equal that they are endowed by their creator with certain unalienable rights that among these are life liberty and the pursuit of happiness considering the health of older persons the following table compared the health map with gender there is clearly observable variation in the frequency of health with respect to gender in case of impairment there was 424 female who had no impairment while 394 had visual impairment and 182 had physical impairment on the other hand 50 had no impairment which is higher ratio than female 313 affected by visual impairment 78 affected by mental as well as physical while 31 by mental impairment data shows that more females are affected as compared to males in case of impairment the data on routine health issues indicate 188 males were having temperature but nonfemale 25 males had cough and 212 females and 78 males had stomach issue while 3 female so far in this data males were observed as more affected but only 188 males faced body aches while 273 females 63 males had bp issues while 121 females and joint pain was faced by 156 of males and 333 females the last health measure including chronic diseases shows that hypertension is more common in females with a ratio of 455 while 141 in males but heart problem is the opposite with 219 in males and 61 in females there are 16 males affected by epilepsy and 3 females 94 males affected by diabetes and 3 females 63 males by arthritis and 91 females 31 males affected by asthma while no females and only females affected by tb and hepatitis with a ratio of 3 for each gender variations can be seen in both biological structures and functions in humans the social structure of culture with its division of genderrelated duties society functions and social status appears to have had a greater influence on gender disparities in quality of life than biological differences it is widely known that though women comprise more than half of the population of the globe and often live longer than males they also spend more years of their life with functional constraints additionally elderly women do much worse on most measures of subjective wellbeing and mental health when compared to males from table 3 the comparative data of healthaffecting diseases indicates that females are more affected but it is also evident that more males suffer from chronic diseases which are the cause of their death as other studies also showed the differences in chronic diseases and other health issues experienced by each gender are a second more credible argument while cancer and heart disease two major causes of death affect males more frequently than women women also experience greater rates of chronic illnesses such as arthritis depression osteoporosis and related fractures unlike cancer and heart disease these illnesses inflict agony but pose less of a threat to life it ultimately answers the paradox of higher female life expectancy than males this intriguing paradox has a few justifications in literature as well legatos studies show that women are physiologically more resilient than men then there is a gender difference in survival at birth with a ratio of 105 males and 95 females additionally men are more likely than women to experience hearing loss neck and back pain and fallrelated injuries as they get older while women are more likely to experience vision loss mental disorders osteoarthritis urine incontinence and frailty as well as women are more likely to have dementia than men due to greater longevity in the context of morbidity vs lifespan another explanation is based on differences in lifestyle between the two sexes in particular smoking and alcohol drinking are habits that are highly associated with and have historically been more common in males although the data differ between european nations an excess of male mortality from all causes exists according to a comparison of smoking and alcoholrelated deaths in 30 european countries men die at higher rates for instance the gender gap in eastern europe often accounted for 2030 of alcoholrelated mortality whereas elsewhere in europe it is just 1020 in several types of research verbrugge found that the gender gap in the use of medical services drug usage and sickness frequency decreases as people get older israeli studies have shown evidence in favor of a decline in gender disparities with aging in protective health behavior and the use of health services in old age conclusion the paper aimed to provide insight into the diseases prevalent in older age including persons more than 60 years of age it explored the health problems faced by older persons in sohan village it can be concluded based on data that there is a relationship between the gender distribution of older persons and their health profile in the data issues of health were presented by focusing mainly on gender differences thus the discussion led to the question of higher life expectancy of females than males the data indicated that chronic diseases leading to death mainly are prevalent in males such as heart attacks while facing issues due to their higher number of daily routine activities and emotional nature

ageing is a natural process that has a vital role in increasing the susceptibility of individuals either male or female whilst they are growing older to reach an age that eventually led them to end on a phenomenon called death like other natural processes it is a kind of complex and simultaneous process where multifactors get attracted and operate on many levels in a functional organism however the current study aims to address aging and its impact on humans whilst categorizing them on a gender basis descriptive research methodology has been employed to assess social support patterns among the aged population of sohan village a statistically calculated sample of 97 has been traced and studied through pursuance with the interview method the study aimed to generate a report based on an understanding of people with different spectacles of beliefs and values regarding the influence of aging on gender along with an assessment of each multifactorial element that affects the individual such as through health mapping health profile evaluation and so on the retrieved data throughout the research has been managed and analyzed whilst using cspro and spss for data entry and analysis software respectively significant conclusions have been presented that revealed a proportional relationship between the gender distribution of older persons and their respective health profiles moreover chronic diseases are most prevalently found in males such as heart attacks leading to death than in females which raises the life expectancy and wellbeing standards of females than males

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introduction according to the 10th edition of the international diabetes federation diabetes atlas diabetes has become one of the fastestgrowing global health concerns in the twentyfirst century currently 537 million adults worldwide have diabetes with a prevalence rate of 105 1 diabetes complications affect multiple organs and lead to high disability and mortality rates in 2021 about 67 million adults died of diabetes or its complications accounting for 122 of the global death toll 1 china had about 140 million diabetics in 2021 ranking first in the world diabetes prevalence among adults increased from 42 in 2002 to 112 in 2017 23 although the awareness treatment and control rate of diabetes improved in recent years they remained low 2 it is urgent to improve the ability of people with prediabetes to obtain appropriate and timely care effectively preventing or delaying complications avoiding premature death and improving their quality of life access to online health information is an essential way for information consumers to improve their quality of life and meet their information needs active access to health information helps individuals understand their health status and medical diagnosis and maintain their health 4 however a large body of research has found that people do not always actively access health information and sometimes deliberately avoid it to maintain or increase their level of uncertainty 56 health information avoidance is a prevalent issue according to research on the information behavior of people with lifethreatening diseases such as breast cancer prostate cancer aids etc some individuals avoid learning about their health status 7 8 9 although some studies have confirmed that reasonable avoidance of health information can temporarily alleviate negative emotions such as anxiety and fear 10 in the long run it affects peoples perception of their health status and may lead to missed opportunities to detect diseases early and improve lifestyle habits 11 online health information avoidance is the behavior presented by individuals of avoiding or delaying access to available online health information 11 some researchers put information avoidance behavior in the context of information seeking 1213 and less in that of information encountering the relevant research on the behavior of information encountering only considered the accidental discovery and active acquisition of unexpected information and ignored the instinct of human beings to generate avoidance motivation for external stimuli thus paying less attention to the avoidance behavior after information encountering 14 online health information encountering is useful or interesting health information that users encountered while searching and browsing which can help users solve past present or future health problems related to themselves or others 14 moreover it plays an important role in disease prevention diagnosis and treatment can optimize health decisions for users improve or change health behaviors and better play the value of health information avoiding such information means that individuals would lose out on early detection of diseases and the correction of unhealthy lifestyles which is not conducive to the flow of information and the realization of information value although there has also been research on whether individuals were willing to accept the detection of type 2 diabetes and diabetics avoidance behavior of health information 15 16 17 the avoidance of diabetes information received less attention therefore it is necessary to explore users avoidance behavior of online diabetes information this study puts information avoidance in the context of information encountering aiming to solve the following questions rq1 what are the major phases that constitute an online diabetes information avoidance process rq2 what happens during each constituting phase in the online diabetes information avoidance process rq3 what are the major factors that influence the occurrence of online diabetes information avoidance rq4 how does each influencing factor act on the occurrence of online diabetes information avoidance literature review health information avoidance research mainly focused on the content and influencing factors of information avoidance and a few studies have explored the avoidance strategies and results research on influencing factors of health information avoidance relevant studies mainly focused on the avoidance of disease health information including cancer 910 diabetes 15 16 17 and daily health information such as skin damage 18 and physical exercise 19 the respondents included patients 17 college students 15 females 920 pregnant women 21 elderly people 22 rural residents 23 and other different groups researchers explored the factors that influenced users avoidance behavior of health information in three aspects userrelated factors informationrelated factors and contextrelated factors userrelated factors female elderly lowincome loweducation and low information literacy users tended to avoid health information related to subjects such as cancer physical exercise and epidemic 192425 another study found that younger users were more likely to avoid information 26 negative emotions such as fear anxiety worry etc led to users avoidance behavior of cancer information 102227 however the direction of the relationship between worry and cancer information avoidance was inconsistent in china and the us 28 perceived risk promoted users avoidance behavior of health information 623 when users believed that the disease was controllable they would avoid health information less 9 compared with people with more coping resources people with fewer were more likely to avoid information 29 cognitive dissonance increased the willingness to avoid information 30 but selfefficacy decreased individuals willingness 3132 individual selfaffirmation helped reduce the avoidance of risk information but increased users avoidance when information may force people to carry out unwanted behaviors and when information was related to the risk of an untreatable disease 33 informationrelated factors researchers found that information overload aggravated users cognitive burden triggered negative emotions such as anxiety and fatigue and led to avoidance behavior 13253435 source credibility information utility and characteristics had an impact on users avoidance behavior 212336 in addition the expression of health information titles affected users avoidance behavior compared with loss frame titles gain frame titles attracted more and longer attention and more clicks 20 contextrelated factors health information avoidance was situational relatively common not necessarily unhealthy and may be used to achieve multiple communication goals 37 people avoided health information mainly to maintain hope or deniability resist overexposure accept limits of action manage flawed information maintain boundaries and continue with lifeactivities 37 social norms behavior changes task driving and society influenced users avoidance behavior 122136 research on avoidance strategies to achieve the purpose of avoiding information people often adopted certain avoidance strategies such as avoiding information sources controlling attention delaying access forgetting information and denying information avoiding information sources in real life people often avoided unwanted information by avoiding specific information sources including newspapers books websites social networking platforms television programs and other people or institutions that may provide information 38 controlling attention even if people had obtained information from information sources they were often unable to focus on information when information conflicted with their cognition and caused discomfort people avoided the information by diverting or distracting their attention 39 people may choose to pay attention to positive information and remain indifferent to adverse or threatening information even though such information may be more useful 40 delaying access when people were unable to process information immediately due to cognitive or emotional factors but were aware that it had potential value they tended to delay accessing it to gain enough time to adjust their cognition or emotional state 41 then they tried to understand the information that had not been obtained after adjusting their state 42 forgetting information even though people obtained the information they still deliberately and selectively did not recall negative information 40 denying information when people tried to forget information and failed they could have a biased understanding or interpretation of the information thus rejecting and denying the original meaning of information transmission 3740 research on avoidance results less attention has been paid to the effect of information avoidance on respondents and the conclusions vary some pointed out that information avoidance brought on negative effects while others believed that it brought on positive effects negative effect the most direct result of information avoidance makes people miss the opportunity to eliminate uncertainty and optimize decision making 11 individuals with health risks often avoided medical examinations which made people miss opportunities for prevention early detection of diseases making better decisions obtaining better treatment and improving lifestyle habits 43 positive effect when people could not or believed they could not change their environment and status quo information avoidance could help them increase cognitive uncertainty alleviate cognition disorders and negative emotions such as fear and anxiety 35 or maintain their original state and firm up their existing decisions or plans 37 maintaining or increasing uncertainty could make patients optimistic and increase comfort which is conducive to treatment and enables patients to temporarily live a happy life 640 at present the related researches mainly focus on the factors influencing the occurrence of health information avoidance behavior devoting less attention to avoidance strategies and results and there is a lack of research on how avoidance behavior occurs researchers pay less attention to diabetes information information encountering often occurs in the online environment this paper tries to put avoidance behavior in the context of information encountering to explore the users avoidance behavior of online diabetes information and reveal the process and influencing factors of avoidance behavior to comprehensively grasp how and why the users avoidance behavior occurs method research method selection because information avoidance was not easy to observe directly the interview method was mainly used to collect qualitative data in previous studies and the diary method was rarely used 11 the diary method is a selfreport method of obtaining and recording the subjects immediate feelings compared with the interview the diary method can help researchers collect dynamic and realtime data from respondents effectively shorten the time interval of recall reduce the risk of retrospective bias and ensure the authenticity of research results 4445 the interview method is also advantageous in obtaining details of user behavior and mental activity and it can be used alone or as a complement to the diary method therefore the interview method with the critical incident technique and the diary method were adopted to collect qualitative data on users avoidance behavior when they encountered online diabetes information respondents selection and recruitment in the previous research on the avoidance behavior of disease information researchers mainly focused on patients obtaining disease information facilitates not only timely diagnosis treatment and daily health care for patients but also health management and disease prevention for nonpatients the patients family members understand the relevant knowledge which can supervise the patients treatment and daily health care to help control the patients condition therefore this study investigated diabetic patients family members of diabetic patients and general users to obtain a comprehensive understanding of users avoidance behavior the authors recruited respondents on different platforms such as the post bar of wuhan university wechat moments diabetes forum qq group of diabetes etc data collection the data were collected from 14 january to 31 march 2022 first the authors told the participants what online diabetes information they encountered was what the avoidance of online diabetes information they encountered was and several forms of avoidance of online diabetes information after that the authors asked them to keep a diary for two weeks providing them with diary points and diary examples the diary points included the time place scene emotional state activities platform whether there was a clear demand before information encountering the way of information encountering the topic and characteristics of the information encountered the reaction to the information encountered the reason for avoidance the strategy result and intensity of avoidance behavior behavior after avoidance etc participants needed to record the avoidance behavior in a diary when it occurred a minimum of 150 words were required to be recorded participants were informed that a minimum number of diary entries was not required and not related to the final reward after they completed their diaries the authors conducted supplementary interviews with them to address what was unclear in the diaries and interviewed them again based on the interview outline which was the same as the diary points to obtain their experience of avoidance behavior affected by the covid19 epidemic the interviews were completed through wechat voice the authors told participants who only participated in the interview that we would record the interview content for the convenience of subsequent data collation desensitize them in the subsequent processing and record them after obtaining consent the authors adjusted the content of the interview according to the actual situation to collect relevant data on the avoidance behavior of the respondents the length of each interview was 1530 minutes seventeen respondents participated in the diary and interview data collection methods including eleven females and six males because there were diabetics around or in their families the respondents were often concerned or willing to learn about diabetesrelated information among them there were two diabetic patients eleven family members of diabetic patients and four general users aged between 19 and 32 with college undergraduate master and doctorate education backgrounds their majors included library science information science information management and information system management science and engineering accounting chemistry communication engineering law clinical medicine etc data preprocessing seventeen respondents contributed fortyseven incidents fortytwo of which come from diaries and five come from interviews since most respondents were first exposed to the concepts of information encountering and information avoiding the phenomena of false information encountering and false information avoiding was inevitably included to ensure the accuracy and effectiveness of this study the authors screened according to the following criteria whether the participants encountered online diabetes information under unexpected situations whether the online diabetes information they encountered was useful or interesting for the participants whether the participants avoided the information they encountered under unexpected situations and excluding the records of avoidance made by the participants due to advertising information unfortunately seven of the incidents were detected to be false as attributable to the following reasons 1 it does not belong to information encountering i38 and i46 users discovered online diabetes information during their active search and had expectations the user actively searched for diet and resting to prevent diabetes on weibo and the user searched for will low blood glucose turn into high blood glucose on baidu the search content had a high correlation with diabetes and users had expectations for the search results of the two incidents 2 it belongs to information encountering i20 i41 i42 i43 and i44 users encountered interesting or useful information in unexpected circumstances and checked the content these instances belonged to information encountering but they did not trigger information avoiding data analysis method the qualitative thematic analysis method included identifying analyzing and reporting patterns or topics in data 46 inductive thematic analysis was based on empirical data and datadriven methods grounded theory was employed to find new phenomena that had not been mentioned in existing research 46 the grounded theory allowed researchers to theoretically explain the general characteristics of the topic through associative patterns while the explanation was based on the empirical observation of the data through categorical coding therefore this study used inductive thematic analysis to analyze and extract the topics involved in the process of avoidance behavior the authors followed the basic analysis steps of thematic analysis that is getting familiar with data generating initial coding formal coding and summarizing topics 46 the authors conducted the thematic analysis as follows the researchers read all the descriptions carefully and took notes for each meaningful unit initial codes were created based on these notes the relationships between the initial codes were analyzed and similar ones were combined to generate formal codes formal codes were refined or incorporated to form subthemes and main themes the authors used grounded theory to analyze and refine the influencing factors of avoidance behavior and followed the threelevel coding process of open coding spindle coding and selective coding the goal of open coding is to extract initial concepts from the original material the goal of spindle coding is to develop main categories based on open coding by refining and merging the initial categories and the goal of selective coding is to further develop core categories based on the main categories results phase of the avoidance behavior process the authors analyzed the remaining 40 true incidents based on thematic analysis to identify the key phases of the avoidance behavior process table 1 provides three examples of the coding process simply speaking a note was a keyword or phrase captured in original descriptions an initial code was a higherlevel abstraction of the phenomenon reflected in a note and a formal code unified several similar initial codes the authors annotated meaningful sentence fragments marking 387 nodes in total generating 136 initial codes such as qq zone weibo and wechat official account after comparing and combining the initial codes 93 official codes such as qq weibo and wechat were finally formed then the authors analyzed the relationship between formal codes classified and merged them according to their similarity in meaning and formed 43 subthemes including social media search engines video platforms etc finally according to the meaning expressed by the subthemes and the correlation between them the authors obtained 15 main themes such as the online environment preencountering emotional state and foreground activities the subthemes were secondlevel themes according to the sequence of occurrence they could be divided into three stages preencountering encountering and avoiding after encountering as shown in table 2 the authors found two characteristics of avoidance behavior dynamic variability of avoidance intensity and avoidance behavior dynamic variability of avoidance intensity included from general to strong avoidance from strong to general avoidance and avoidance behavior depending on the specific situation dynamic variability of avoidance behavior included from avoidance to nonavoidance from nonavoidance to avoidance unchanged and avoidance intensity depending on the specific situation preencountering the participants everyday life study and work provided the context for their online diabetes information encountering three incidents were missing activity scenes liferelated scenes such as shopping socializing searching for health knowledge or just killing time accounted for the absolute majority of incidents in contrast relaxing during doing homework reading literature writing an opening report or solving problems users encountered during the study were typical studyrelated scenes in workrelated scenes users mainly killed time during breaks the foreground activities before the information encountering mainly included browsing searching and social interaction the term browsing was used here in a broad sense it may be that users opened mobile devices to view the latest information or used social media video platforms search engines etc to consume various information browsing aimlessly without specific goals was especially helpful for information encountering in contrast prior activities were identified in five of these incidents to solve problems in everyday life and studying users searched and then encountered the information even when the users explicit target was covered by an entirely different implicit target social interaction was found in everyday liferelated scenes such as chatting and playing games instant messaging services such as wechat had promoted the information exchange of network users when establishing or maintaining online social relations the users emotional state of preencountering influenced their reaction and attitude to health information which could be classified as positive or negative positive emotional states were mainly manifested in leisure happiness relaxation etc while negative emotional states were mainly manifested in sadness grief pain etc users were mostly in positive emotional states and less in negative emotional states in preencountering it was easier to avoid the online diabetes information encountered in a negative emotional state encountering users avoidance behavior began when they noticed stimulus elements in the information that they encountered which caused users to deviate from the original exploratory behavior and make cognitive and behavioral responses according to their cognition and needs 47 the information content of preencountering and encountering mainly had two types 1 when users browsed or searched irrelevant content on health such as wechat moments news foods painting etc users encountered diabetes information 2 users encountered diabetes information when browsing or searching for general health information such as fat reduction and renal failure stimulus noticed the topic and presentation of the online diabetes information encountered attracted users attention the topics of the online diabetes information encountered included diagnosis and examination treatment daily health care complications social life prevention scientific research etc the topics of complications and scientific research were more likely to be avoided by users than other topics most users felt that the content related to complications was too uncomfortable users avoided scientific research due to their poor readability users read or watched text pictures videos and other forms of content reaction to stimulus after noticing the online diabetes information they encountered users matched their cognition and needs with their knowledge and the needs of themselves or others and responded behaviorally users immediately avoided or further accessed the online diabetes information encountered users immediately avoided online diabetes information including avoiding information sources and delaying access when the online diabetes information encountered caused users discomfort such as panic irritability rejection etc users would immediately avoid information sources when the user was inconveniently obtaining the online diabetes information encountered due to time or place constraints he would delay access users further accessed the online diabetes information encountered when the user thought that the online diabetes information he encountered was useful or interesting he would access the online diabetes information further users would examine the specific content when they found the title of the online diabetes information attractive and useful to them or others guiding patients in their medication and satisfying their knowledge needs when users found the information interesting or novel it would arouse their curiosity and drive them to click on the content to examine it content examined even if users examined the online diabetes information they encountered it did not mean they would accept and use it the users surroundings user information access preferences and content affected the users reaction and emotional state after examining the online diabetes information he encountered which in turn affected subsequent behavior if the readability of the online diabetes information they encountered was poor it would reduce users interest in reading resulting in users distraction or withdrawal from the current read practicality also had an impact on users judgment about the value of the information encountered when information caused users cognitive conflict users would choose to avoid the current information after examining the online diabetes information encountered it gave rise to users positive or negative emotional states positive emotional states motivated users to use the information further while negative emotion tended to lead to avoidance behaviors avoiding after encountering after information encountering users adopted some strategies to avoid the information encountered due to cognitive imbalance or emotional discomfort to reduce the impact of the information encountered on them 11 avoidance strategies and their manifestations confronted with the online diabetes information encountered users adopted some strategies such as avoiding information sources controlling attention delaying access forgetting information and denying information it should be noted that the user may adopt multiple avoidance strategies in an incident for example the user first avoided information sources and then forgot information even if users adopted the same avoidance strategy its manifestation could also be different the manifestations of avoiding information sources included directly swiping these away staying away from information sources quitting reading information withdrawing applications turning off mobile phones etc the manifestations of controlling attention included quickly browsing the information content by distracting ones attention examining some content that conformed to the current stage or only being distracted by other content even if other contents were also useful the manifestations of delaying access users delay access to information when they encountered it at a time where there was time pressure or inconvenient access to the information users found the information useful for themselves and patients but they had difficulty remembering or implementing it they would record collect save share etc for subsequent access the manifestations of forgetting information a the information was useful but it was not useful at the current stage users selectively forgot or directly ignored the information encountered b the information was useful but it caused users discomfort or disturbed users current life state users chose to forget the information encountered to maintain the current state c the information was useful but the information content or suggestions was not easy to practice users chose to ignore the information d the information was useful but users felt that the complications of diabetes were not easy to prevent users did not want to think of it e the information was useful but it was different from the users actual situation so the user no longer remembers it the manifestations of denying information when the information content or suggestion obtained was inconsistent with the users inherent ideas or habits the user would deny them to maintain his current behavior avoidance intensity it included general avoidance and strong avoidance in most cases users generally avoided it based on the information and its content compared with daily health care prevention and treatment of diabetes complications and professional academic research were more likely to cause strong avoidance by users when users were in group activities in public places or depressed they were more likely to avoid the health information encountered the effect of avoidance behavior its positive effects were mainly manifested in reducing worry and discomfort improving the efficiency of information acquisition and reducing cognitive burden the negative effect was mainly manifested in reducing the acquisition of health knowledge which was not conducive to disease prevention for family members of diabetic patients and general users who thought that they could not implement the content or suggestions of online diabetes information by themselves or they were in good health with low information demand avoiding the online diabetes information encountered had little or no effect on them the emotional state and behavior after avoiding avoiding information might maintain or reverse users emotional state strengthen or weaken their initial emotions showing positive or negative emotional states which further affects their subsequent behavior they performed the following behaviors 1 returning to the initial activity before information encountering 2 ending all activities 3 using the information encountered 4 further exploring in addition users avoidance behavior had two characteristics including the dynamic variability of avoidance behavior and avoidance intensity vertically user behavior was dynamic it changed from avoidance to nonavoidance and from nonavoidance to avoidance once the avoidance preference has been formed it will not change in a short time from avoidance to nonavoidance users pointed out that they had never learned about information related to diabetes in the past and believed that only people with diabetes needed to be concerned about some information so they had been avoiding it after they inadvertently learned about their utility they no longer avoided such information therefore it is feasible and necessary to promote and disseminate diabetes knowledge among general users and family members of diabetic patients in addition users decide whether to avoid online diabetes information depending on the stage they are in from nonavoidance to avoidance this occurred mainly for specific information sources and information content when users knew that certain information sources were unreliable or had low information value they would avoid information on that source in addition users avoidance behavior varied with their health status cognitive level knowledge needs information content and the environment when faced with the same topic or content from an information source depending on the specific situation the dynamic variability of users avoidance behaviors suggests that interventions can be made to improve users utilization of information resources and facilitate information flow however some users avoidance behaviors are unvarying for topicspecific content or information from a specific information source users always avoid it users willingness to avoid has a dynamic change from general avoidance to strong avoidance and from strong avoidance to general avoidance depending on the context factors influencing the occurrence of avoidance behavior based on the idea of grounded theory the authors extracted 246 original sentences and corresponding initial concepts from the initial material generating 86 initial concepts such as practical academic and useful after comparing and combining the initial concepts 37 categories were finally formed such as practicability readability and usefulness table 3 provides three examples of the coding process analyzing and integrating those categories 15 main categories were formed such as information quality information overload and information dissemination finally according to the meaning of the main categories and their interrelationships they were summarized into five core categories informationrelated factors userrelated factors environmentrelated factors emotionrelated factors and information avoidance behavior as shown in table 4 the authors extracted three informationrelated factors from the data including information quality information dissemination and information overload when users perceived that the information quality was not high or not as good as expected they would avoid the online diabetes information encountered the information was of poor practicality low usefulness poor readability and unreliable content consistent with the previous research results 2641 this article contained a lot of arguments in chinese and english i learned that sugar was closely related to many diseases such as diabetes but this article was too long and had too many confusing arguments it was very professional many academic concepts were very boring for ordinary people to read i pass it quickly information dissemination including information source reliability information title description information topic and information presentation was related to the realization of information value users generally did not directly avoid trusted information sources and information published by certified and authoritative publishers i thought what he said was very authoritative users tended to read novel professional clear and rigorous titles and avoided frightening and lengthy titles i usually dont read those unprofessional titles whether the information topic and the title could attract users attention was directly related to whether the information could be further utilized from the analysis results users tended to avoid information about diabetes complications severe or painful experiences caused by diabetes and scientific research progress i would always avoid diabetes complications i wouldnt look at information about severe experiences caused by diabetes information in graphic form was easier to be noticed for users if it had pictures i would read more i thought the text looked intuitive and fast information overload caused by excessive information feeds and high similarity gave rise to users cognitive overload triggering negative emotions which led to avoidance it was consistent with the previous research conclusions 132534 i didnt turn off the notification of the applications such as quark and baidu but they always sent me such notifications i didnt have time to look at these notifications i turned them off without looking at them i would avoid it due to a large amount of similar information userrelated factors the authors extracted five userrelated factors from the data including information sufficiency healthbehavior perception demographic characteristics perceived threat and perceived control information sufficiency was determined by the gap between the information that an individual had and the amount of information required when the gap was small the user was prone to avoid it then i didnt know much about insulin yet i want to find out which is better to take medicine or insulin healthbehavior perception was the users subjective judgment of the difficulty and utility of health behavior which affected the users willingness to avoid it if the content or suggestions of the online diabetes information they encountered were easy to implement and had good utility users would use the information if it was effective but difficult to implement users would choose to forget the information but in my current state of life it was hard to do what it required so i didnt think about it anymore i knew about blood glucose regulation and how it affected diabetes fat and the whole body then i learned that blood glucose was still important later when i came across information about blood glucose i would read it too demographic characteristics affected the users perception of health information when they encountered online diabetes information when the user was in poor health the users needs would increase which reduced the possibility of avoidance in addition personal or family history of disease influenced users judgment of online diabetes information recently i had backache decreased immunity and other conditions in addition it was said that diabetes was hereditary more and more news says that diabetes was at a younger agetherefore i was more interested in seeing this information about the blood glucose control experience perceived threat including perceived severity and perceived susceptibility influenced users attitudes toward online diabetes information when the user perceived diabetes susceptibility the user was more willing to obtain daily health care and prevention information and reduced the possibility of direct avoidance when users perceived diabetes to be severe being confronted with the online diabetes information encountered especially diabetes complications or other serious consequences increased users worry and fear which promoted the occurrence of avoidance behavior perceived control refers to the users perceived control over the information and the consequences of his actions when the patient perceived that his condition was stable he was more confident which would reduce the likelihood of avoiding information about diabetes environmentrelated factors the authors extracted four environmentrelated factors from the data including context type behavior place time pressure and social factors context type mainly refers to foreground activities including browsing searching social interaction studying working and everyday life compared with browsing the user was more likely to avoid the online diabetes information encountered while searching and during a social interaction users tended to directly seek the target content in the search scene which reduced the possibility of obtaining the online diabetes information encountered and increased the users willingness to avoid it the online diabetes information encountered by the user interrupted his mental state in the social interaction scenario and thus led to avoidance i didnt know how to distribute the questionnaire i began to search the variable scale with the mobile phone as soon as i opened the homepage i was pushed a bunch of articles on diabetes treatment and prevention i should have read such preventive articles before but now i was too busy to finish my task therefore i quickly crossed them away however most users browsed aimlessly or randomly when the online diabetes information encountered was useful or interesting users would further obtain it with plenty of time in the everyday life scene users did not directly avoid the online diabetes information encountered but it was easy to occur in the study and work scene after browsing the weibo homepage i was pushed a blog post then i opened the full text and had a look behavior place when users were in public places their behavior was restricted by their surroundings thus reducing the probability of obtaining information about online diabetes they encountered and increasing their willingness to avoid it when i was relaxing in the office not alone i was interested in the information but i didnt bring headphones at that moment i wanted to collect it and then check it with headphones when i at the dormitory i would like to see some information that would help me understand the disease but i didnt want to see this when there were people around me if there were a lot of people i would directly delete it regardless of whether its content was useful to me or not time pressure refers to the lack of free time when users encounter online diabetes information which refers not only to the feeling of not having enough time but also to the emotional experience of being rushed and overwhelmed 47 when users are busy or in situations of time constraints they avoid the online diabetes information they encounter deliberate avoidance just when you are busy social factors in this paper referred mainly to subjective norms that is the pressure from others or society that users felt while deciding whether or not to examine the online diabetes information they encountered the impact of subjective norms on avoidance behavior was more pronounced in patients the user mentioned that she didnt want others to know that she was concerned about online diabetes information and would directly avoid online diabetes information she encountered when in a public place regardless of whether the information was useful emotionrelated factors the authors extracted two emotionrelated factors from the data including the emotional state of preencountering and postencountering positive emotional states promoted user approach behavior and negative emotional states led to users avoidance behavior based on the results of the above analysis a model of online diabetes information avoidance behavior in the context of information encountering was obtained as shown in figure 1 it should be noted that not all incidents contain every element in the process of avoidance behavior discussion and implication implications of the phase in the process this study puts the avoidance behavior in the context of information encountering which was complementary to previous information avoidancerelated researches and contributed to the understanding of the information avoidance process effective information stimuli help reduce information avoidance avoidance behavior begins with the users attention to the information encountered in terms of avoidance strategies avoiding information sources was adopted most this showed how attracting users attention during information dissemination and thus facilitating their click behavior was the first step in helping to realize the value of information from the results of the analysis the information that helped control and prevent diabetes could guide the users practice could attract their attention and trigger further examination in the future researchers can explore which topics presentations and informationorganization methods are more conducive to attracting users attention and clicking guiding better information flow and information value avoidance behavior can be intervened users avoidance behavior from avoidance to nonavoidance suggested that appropriate publicity and guidance would help users reduce avoidance of useful online diabetes information facilitate the flow of online diabetes information achieve the value of the information and help change users unhealthy behaviors and improve their health users avoidance behavior from nonavoidance to avoidance meant that after successfully attracting users at the beginning how to maintain user stability reduce user churn and enhance user stickiness should be considered in terms of avoidance intensity many users showed a strong avoidance intention of topics such as diabetes complications patients painful experiences and scientific research while users showed a general avoidance intention of most other topics since diabetes can lead to various complications diabetic patients and family members of diabetic patients need to learn about diabetes complications such as preventive measures for complications during the dissemination of diabetes complications more attention should be paid to the prevention of various complications to attract users attention a small amount of information about the serious consequences of complications can also be added the intensity of user avoidance was dynamic especially the change from general avoidance to strong avoidance which indicated that when propagating diabetesrelated information to users it is necessary to ensure the quality of information and the credibility of the information source to reduce the loss of users implications of the influencing factors this study identified 14 factors that influenced the occurrence of avoidance behavior they were further recognized as userrelated informationrelated environmentrelated and emotionrelated factors targeted countermeasures can be conducted from userrelated informationrelated and environmentrelated factors to reduce the occurrence of avoidance behavior userrelated factors demographic characteristics including health status personalfamily disease history and habits were stable factors and difficult to change and it was difficult to intervene in users avoidance behavior through them on the other hand healthbehavior perception perceived threat perceived control and information sufficiency was dynamic and users avoidance behavior could be intervened through them healthbehavior perception when deciding whether to implement the content or suggestions of the online diabetes information encountered general users diabetic patients and family members of diabetic patients would first consider barriers and benefits online diabetes information will only be accepted and used by them if it is within an acceptable range of difficulty of implementation and utility perceived threat currently the awareness rate of diabetes is still low many people thought that if there were no diabetic patients in their families the possibility of suffering from diabetes was low paying no attention to the prevention of diabetes in their daily life it is necessary to increase the awareness of diabetesrelated knowledge enhance users awareness of the susceptibility and severity of diabetes and help them form healthy living habits perceived control through interviews with patients and their families we learned that elderly patients have a good mentality pay attention to daily health care and have good condition control the newly diagnosed younger patients had large emotional fluctuations when facing diabetes and were prone to give rise to negative emotions when facing such information cases or stories can be used to explain to them that diabetes is manageable and to increase their confidence in coping with the disease information sufficiency it was affected by information demand and knowledge reserve and was determined by the gap between the users knowledge reserve and information demand when user information demand is greater than the current knowledge reserved users tend to acquire knowledge on the one hand it is necessary to clarify which diabetes information users are interested in according to their usage habits on the other hand it is necessary to include new information in the recommendation process to increase their reading possibilities informationrelated factors it includes information dissemination information quality and information overload information dissemination including information source credibility title description information topic and information presentation from the results of the analysis in addition to complications severe or painful experiences caused by diabetes and scientific research other topics of online diabetes information were of high concern to the general users diabetic patients and family members of diabetic patients in terms of complications the information on how to prevent complications is more acceptable to users than the consequences caused by complications in terms of scientific research some users pay attention to the research that can be implemented diabetesrelated severe or painful experiences might alert individuals to the seriousness of the disease and draw their attention therefore it is necessary to consider a more acceptable way to present this information to users title description users were more interested in viewing rigorous professional and focused titles how titles are expressed can attract users attention and stimulate reading interest needs further verification existing research found that message framing and evidence types influenced users health information adoption and behavior change in the future we can explore whether message framing and evidence types can play a role in attracting users attention and reading online diabetes information and compare whether there are differences between them information sources credibility includes trusted information release channels and trusted information publishers most users preferred to read the content posted by experts such as doctors and professors on official platforms such as hospital online platforms wechat official accounts authentication weibo tiktok etc while a few users were more concerned with patients personal experiences and daily health care information distribution platforms can increase information filtering ensure the authority of information publishers and published content and enhance users trust in information sources thus reducing direct avoidance caused by information sources and promoting information flow information quality for different users it is necessary to explore which information presentation method can achieve better communication effects highquality information with high readability usefulness and practicality will stimulate users interest in reading and increase the possibility of information being used lowquality information with poor readability uselessness and low practicability will directly lead to user avoidance high information quality is the key to ensuring continuous information flow and access to information therefore it is necessary to ensure information quality information overload including high pushing frequency large pushing quantity and high similarity are important factors that cause users to avoid it the appearance of a large number of similar information will arouse users visual fatigue to ensure better information dissemination the platform should appropriately control the amount of information dissemination to reduce the cognitive burden of users environmentrelated factors in the browsing context users are more likely to encounter online diabetes information and view it when browsing aimlessly in the process of intelligent recommendation a focus on the information push in the browsing context is recommended conclusions and future research this study focused on users avoidance behavior of online diabetes information under the background of information encountering diary and interview methods were used to collect data on the avoidance behavior of diabetic patients family members of diabetic patients and general users based on the thematic analysis method and grounded theory the authors analyzed the process of users avoidance behavior and its influencing factors the results show that the process of users avoidance behavior includes three phases preencountering encountering and avoiding after encountering first browsing searching or social interaction provides the context for encountering second the encountering occurrence consists of three stepsnoticing the stimuli reacting to stimuli and examining the content and third to avoid the online diabetes information users encountered users will adopt avoidance strategies such as avoiding information sources controlling attention delaying access forgetting information and denying information which is manifested as general avoidance and strong avoidance it has positive negative or no effect on users after avoiding users will take actions such as returning to the preencountering activities ending the current activities and further exploring and using the information encountered avoidance behavior and avoidance intensity are dynamic avoidance behavior is affected by userrelated factors informationrelated factors environmentrelated factors and emotionrelated factors the limitation of this study is that it only reveals the process and influencing factors of avoidance behavior of online diabetes information from a qualitative perspective and does not further verify the mechanism of the process and influencing factors of avoidance behavior the data obtained from the interview comes from the users memory which is less complete than the diary leading to an incomplete process of avoidance behavior based on interview data in the future we need to conduct indepth research on the avoidance behavior of health information from the perspective of research content and research methods and conduct an indepth analysis of different phases of avoidance behavior from the aspect of the content for example in the preencountering phase we can explore the contributing factors of health information encountering in the encountering phase we can analyze how users cognition evolves and what characteristics of health information will lead to users approach or avoidance in the avoiding after encountering phase we can explore how factors act on users avoidance behavior and the mechanism of emotional factors on users avoidance behavior and weigh the influence of individual beliefs on the selection and interpretation of health information in terms of research methods qualitative data can be collected by combining observation methods and objective data on users avoidance behavior can be obtained by eyetracking experiments in addition data analysis can be combined with qualitative comparative analysis and simulation analysis to systematically reveal the complex relationship between the influencing factors of avoidance behavior and enhance the reliability of the conclusion data availability statement the data of the work can be provided by the corresponding author upon request

users avoidance behavior of health information has received growing attention recently but research into users avoidance behavior of diabetes information remains limited this paper aims to reveal the process and the factors of avoiding online diabetes information the interview conducted with the critical incident technique and the diary methods were used to collect 40 true incidents of online diabetes information avoidance from 17 participants based on the thematic analysis method and grounded theory the data were analyzed to identify the key phases of the avoidance process and obtain the factors influencing the occurrence of avoidance behavior the results showed that the macroprocess of online diabetes information avoidance comprised three phases preencountering encountering and avoiding after encountering first browsing searching or social interaction provide the context for encountering second the encountering occurrence consists of three stepsnoticing the stimuli reacting to stimuli and examining the content and third to avoid the online diabetes information encountered users will adopt avoidance strategies such as avoiding information sources controlling attention delaying access forgetting information and denying information which is manifested as general avoidance and strong avoidance and has positive negative or no effect on users the 14 influencing factors of avoidance behavior obtained were divided into four clusters userrelated factors include demographic characteristics healthbehavior perception perceived threat perceived control and information sufficiency informationrelated factors include information quality information overload and information dissemination environmentrelated factors include context type behavior place time pressure and social factors and emotionrelated factors include the preencountering and postencountering emotional states these findings can guide the intervention of information avoidance behavior

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background female entertainment workers are typically young women in developing countries particularly in asia who work at establishments such as karaoke bars restaurants beer gardens or massage parlors entertainment work is often associated with sex work 12 where women employed as singers beer promoters or masseuses sell sex to male patrons to supplement their income fews in particular those who participate in sex work are at greater risk for health problems than the general women population due to occupational hazards such as engaging in unsafe sex exposure to violence and drug use 1 2 3 this group can be difficult to reach with health services due to the hidden and stigmatizing nature of their work 23 despite these occupational stressors mental health of female sex workers is understudied 4 the most relevant data on the mental health of this population come from studies assessing the mental health of fsws available evidence suggests that fsws experience worse mental health outcomes than the general public such as high rates of anxiety depression posttraumatic stress disorder and psychological distress 4 5 6 7 these poor mental health outcomes have been associated with experiences of violence childhood trauma drug addiction and the experience of stigma as reported in a review of the literature 8 the existing evidence does not establish a temporal relationship but suggests that there is likely a bidirectional relationship between poor mental health and sex work studies suggest that poor mental health among fsws can lead to more health risk behaviors such as substance use or unsafe sex in china and iran studies have shown that fsws with severe depressive symptoms were less likely to use condoms consistently 910 and in the united states and puerto rico fsws exhibiting depressive symptoms were more likely to engage in unsafe drug use practices such as needle sharing 11 12 13 these studies suggest that fsws experiencing poor mental health are at greater risk of contracting hiv in cambodia the patterns of entertainment work have changed dramatically which complicates the provision of any type of health services the global financial crisis of 200708 which lead to high unemployment in the garment sector and the 2008 law on suppression of human trafficking and sexual exploitation that banned brothelbased sex work 14 have created a large influx of young women working in the entertainment and informal sex industry today more young women than ever are working in karaoke parlors restaurants beer gardens massage parlors bars or nightclubs at these establishments some women engage in sexual relationships in exchange for money gifts or other benefits for themselves or their family 15 many fews in cambodia come from lowincome rural households have low education levels and have received only limited health education 14 as urban migrants these women face a changing social context and increased stigma with less social support 1617 these factors may result in an increasing vulnerability to mental health problems for this population the breakdown of the traditional brothelbased sex industry and the emergence of indirect methods of selling sex through entertainment venues have created challenges to identifying fews and providing services to address their health issues and needs including sexual and reproductive and mental health the nature of fews is unique to the cambodian context and their health situations and behaviors are somewhat different from and more complex than the situations of fsws in most other countries in addition supportive services for mental health for the general public in cambodia are extremely limited 18 reaching fews with any type of health services can be difficult and with the limited available mental health services in the country addressing the mental health needs of this population is very challenging identifying fews at higher risk for psychological distress based on risk factors may be one way to maximize scarce resources and provide comprehensive mental and physical health services to the most vulnerable women this study aims to identify the factors associated with psychological distress among fews in cambodia methods study sites sampling and training data used for this study were collected in april and may 2014 as part of an impact evaluation of the sustainable action against hiv and aids in communities project implemented by khana the largest national nongovernmental organization providing integrated hiv prevention care and support services at the community level in cambodia participants were recruited from entertainment venues and hotspots from a list obtained from khanas partners who implemented the sahacom programs in the capital city of phnom penh and siem reap province the number of fews in phnom penh and siem reap represents approximately 70 of the total fews population in cambodia 19 the sample size was proportionally allocated to the number of fews in two study sites the details of the study have been published elsewhere 2021 a twostage cluster sampling method was used to select participants from the two provinces at the first stage the probability proportionaltosize sampling method was used to select entertainment venues and hotspots from the list at the second stage a proportionate number of fews were randomly selected from the each selected venue and hotspot inclusion criteria for the study included biologically female at least 18 years of age able to present themselves on the day of the interview and able to provide consent to participate in the study all research team members were trained for three days on the study methods interview techniques privacy assurance and confidentiality the training also addressed quality control strategies such as rechecking and reviewing the questionnaires after administration and resolving issues that might arise during the fieldwork data collection team leaders were encouraged to perform regular reviews on the progress of the field work and communicate any issues that may occur during the data collection questionnaire development and measurements cambodian research staff members that regularly work with fews developed a structured questionnaire in english and then translated into khmer the national language of cambodia the khmer questionnaire was backtranslated and pretested with a sample of 10 fews in phnom penh to ensure that the wording and contents were culturally suitable and clearly understandable for the respondents we also sought for comments from experts working on hiv in key populations in cambodia and the questionnaire was finalized based on their feedback and findings from the pilot study standardized tools were adapted from previous studies in the same population 22 the most recent cambodia demographic and health survey 23 as well as from other studies in cambodia 2425 sociodemographic characteristics included age marital status completed years of formal education average monthly income living situations types of establishment they were working for and duration they had worked in the current career as well as in the current venue in addition we also collected information on selfperception of the level of hiv risk compared to the general population selfrated overall health and quality of life suicidal thoughts and suicidal attempts in the past 3 months to measure substance use participants were questioned about whether they used any kinds of alcohol and illicit drugs in the past 3 months they were also asked to report the average number of days they got drunk and types of illicit drugs they used in the past month several variables on sexual and reproductive health were measured including number of sexual partners in the past 12 months number of partners with whom they had sexual intercourse in exchange for money or gifts number of partners with whom they had sexual intercourse not in exchange for money or gift and condom use with both types of sexual partners in the past 3 months for condom use we asked during the past 3 months how often have you used condoms when you had sex with your sweetheart the same question was used to assess condom use when having sex in exchange for money or gifts the participants answered these questions on a likert scale with sixpoint response options ranging from always to never those answering always to the questions were considered consistent condom users the respondents were also questioned whether they had clients who requested them not to use condoms in the past 3 months whether they were able to find condoms when they needed in the past 3 months whether they had been diagnosed with an sti in the past 3 months and whether they had been tested for hiv in the past 6 months history of induced abortion was assessed via a question during your work as a few have you experienced any induced abortion with three response options never had sexual intercourse no or yes in addition a yes no question was used to ask whether the participants were currently using any contraceptive method adverse childhood experiences were measured using five questions adapted from the brief screening version of the childhood trauma questionnaire 2627 the questions collected information on the experience of physical abuse emotional abuse sexual abuse physical neglect and emotional neglect with five response options ranging from never to very often participants who responded never and rarely were grouped together as those without aces and those who answered sometimes often and very often as those with aces the cronbachs alpha for the childhood trauma questionnaire among fews in this study was 068 we also adapted five items from the brief screening version of the childhood trauma questionnaire to enquire about family dysfunction 2627 the items collected information on witnessing violence against a family member having an alcoholic or drug user family member having a family member who was depressed mentally ill or who has attempted suicide having parents who had been separated or divorced and having a family member who has been to prison the response options for all the items were yes or no except for having parents who had been separated or divorced for this item another response option was added to indicate if one or both parents had died in the analysis participants whose parents had divorced or separated were grouped together with participants whose parent had died a short version of the general health questionnaire 28 was used to measure psychological distress ghq12 has been validated in asian populations 2930 each item was rated on a fourpoint likerts scale ranging from 0 less than usual to 3 much more than usual the scoring method 0011 was adapted meaning that responses of 0 or 1 were coded 0 and responses of 2 or 3 were coded 1 this has been suggested as it is believed to help eliminate biases resulted from respondents who tend to choose responses 0 and 3 or 1 and 2 31 the mean score for the whole sample was used as the cutoff to define lower and higher levels of psychological distress as it provides a rough guide to the best threshold 32 the cronbachs alpha for the ghq12 among fews in this study was 076 data analyses double data entry was performed using epidata version 3 in bivariate analyses we used χ 2 test or fishers exact test when sample sizes were smaller than five in one cell for categorical variables and students ttest for continuous variables to compare sociodemographic characteristics selfrated overall health and quality of life selfperception of hiv risk substance use and sexual behaviors among fews who had a lower level of psychological distress to those among fews who had a higher level of psychological distress a multivariate logistic regression model was then constructed first we included all variables associated with psychological distress in bivariate analyses at a level of p 005 in the model all variables with a pvalue 005 were then removed from the model and the model was refitted the steps were repeated until pvalues of all remaining variables were 005 in the final model adjusted odds ratio were obtained and presented with 95 confidence intervals and pvalues spss version 22 was used for all statistical analyses ethical statement the national ethics committee for health research of the ministry of health cambodia approved this study a written informed consent was obtained from each participant after they were made clear that participation in this study was voluntary and that they could refuse or discontinue their participation at any time we protected privacy of the respondents by conducting the interviews at a private place and no personal identifiers were collected in the questionnaires or field notes results this study included 657 fews 785 from phnom penh and 215 from siem reap of this total 432 had ghq12 scores of greater than 3 indicating that they have high levels of psychological distress descriptive statistics of demographic characteristics are presented in table 1 the mean age was 256 years old and the mean years of formal education completed was 64 marital status included never married married and living together and divorcedseparated widowed women worked at karaoke bars restaurants and other establishments including beer gardens nightclubs bars massage parlors and streets their average monthly income was 220 on average women worked in entertainment careers for 282 months and worked at their current venue for 180 months a significantly higher proportion of women with a higher level of psychological distress reported having never been married women reported that they felt they were at higher the same and lower hiv risk compared to the general population most women reported good overall health and good quality of life of the total 195 reported ever considering suicide and 73 reported ever attempting to commit suicide a significantly higher proportion of women with a higher level of psychological distress reported a perception that their hiv risk was higher compared to the general population that their overall health was poor that their overall quality of life was poor and that they had thought about committing suicide in the past 3 months substance use among the participants is presented in table 2 in the past 3 months women reported having had at least one full glass of alcohol and being forced to drink at work in the last month women reported getting drunk an average of 187 days and consuming an average of 62 cans or glasses of alcohol per day in the past 3 months 17 of women reported using any kind of illicit drugs a significantly higher proportion of women with a higher level of psychological distress reported having had a full glass or a can of alcohol having been forced to drink at work and having used illicit drugs in the past 3 months sexual and reproductive health behaviors are reported in table 3 women reported a mean number of 28 sexual partners in the past 3 months of the total 372 of women reported having sweethearts or romantic relationships and of those 307 reported always using condoms with their sweethearts of the total 228 reported having had sex in exchange for money in the past 3 months and of those the mean number of clients was 36 women reported being able to find condoms when needed always using condoms with clients and having had clients requesting not to use condoms in the past 3 months in the past 3 months 227 of women reported being diagnosed with an sti and 379 reported currently using a contraceptive method in the past six months 528 had been tested for hiv of the total 610 reported having ever been pregnant and 180 reported having ever had an induced abortion a significantly higher proportion of women with a higher level of psychological distress reported having had sex with a sweetheart but a lower proportion of them reported being able to find condoms when they needed moreover a significantly higher proportion of women with a higher level of psychological distress reported having had a client requesting not to use condoms having been diagnosed with an sti and using a contraceptive method table 4 presented aces and family dysfunction among fews in this study during childhood women described being physically hurt that needed medical care having a family member who said hurtful or insulting things to them having had someone who touched them in a sexual way having had someone who took care and protected them and having had someone in their family who made them feel loved within their families women reported having a parent or guardian who had been physically abused having a family member with a drinking or drug use problem had a family member that was depressed or mentally ill having had parents that were ever separated or divorced and having a family member who had ever been to prison of these experiences a significantly higher proportion of women with a higher level of psychological distress reported having been physically hurt having had family members say hurtful or insulting things and having been touched in a sexual way furthermore a significantly lower proportion of them reported having had someone to take care of or protect them when they were growing regarding family dysfunction a significantly higher proportion of women with a higher level of psychological distress reported having had a parent who was physically abused having had a family member with a drinking or drug problem having had a family member who was depressed or mentally ill and having had a family member who had been to prison the results of multivariate logistic regression analysis are presented in table 5 controlling for confounding factors women with a higher level of psychological distress remained significantly more likely to rate their overall health as poor rate their quality of life as poor have suicidal ideation in the past three months rate their hiv risk as higher than the general population have been forced to drink at work discussion almost half of the fews in our study experienced high levels of psychological distress it is difficult to compare this proportion with other studies because most studies focus on mental health of fsws yet not all fews are engaging in transactional sex and because mental health is measured differently in each study in china two studies measured depression by using the center for epidemiologic studies depression scale and found that 62 9 and 49 33 of fsws had a high level of depressive symptoms in australia a study that used beck depression inventory ii found that 54 of fsws reported experiencing severe depressive symptoms 6 and in switzerland a study that used the composite international diagnostic interview tool found that 50 of fsws had a psychiatric disorder 5 our findings suggest that poor mental health is associated with negative childhood events such as having a history of emotional abuse or having a parent or guardian who was physically abused several studies support the relationships that fsws are more likely to have experienced traumatic events in childhood and those who have are more likely to experience depression 34 the majority of respondents in our study rated their own health and quality of life as good this finding is not consistent with a study of fsws in china where only 75 women were satisfied or very satisfied with their life 35 but fews who had poor mental health in our study were more likely to rate their overall health and quality of life as poor this finding is consistent with psychological literature relating poor selfrated health to depressive symptoms 36 women who had more psychological distress were more likely to perceive their risk of contracting hiv as higher than the general population this represents an accurate view of their risk since fsws who are experiencing psychological distress are more likely to engage in hiv risky behaviors 9 10 11 12 13 still over half of the respondents perceived the level of their hiv risk to be lower than the general population which is an inaccurate identification of their level of risk and therefore may be appropriate recipients of hiv education and risk awareness risk perception has been theorized to be an important motivation for adopting protective behaviors 37 in our study one in five of the women reported ever thinking about committing suicide and almost one in 10 ever attempted this finding is similar to a study of fsws in china that found that the prevalence of suicidal thoughts and suicide attempts in the last 6 months to be 143 and 84 35 women who had more physiological distress were more likely to report suicidal ideation in the past three months this finding has important implications for future service delivery given that levels of suicidal ideation are so high the ghq12 should be used as a screening tool to detect of psychological distress and prompt providers to enquire about suicidal ideation and appropriate followup women in our study with a higher level psychological distress were more likely to report being forced to drink at work in the past three months this is not an uncommon experience for fews and can be seen as an indicator of the kind of workplace environment within which they work 1415 the type of work environment for fews can vary and depends particularly on whether a manager or supervisor pushes women to drink or protects them from that pressure occupational health literature provides support for the findings that employees who perceive low autonomy over their work are more likely to develop psychological disorders 38 in october 2014 the cambodian ministry of labor and vocational training has issued a new regulation that calls for the protection of the occupational safety health and labor rights of all fews 39 while this regulation has not yet been fully implemented or enforced future programming for fews can use this legislation to promote better work environments finally our study found that women with a higher level of psychological distress were more likely to have clients who requested not to use condoms and less likely to find condoms when they needed it our study design does not allow us to see which factor precedes the others but it is likely that many of the factors previously discussed are involved in this relationship in particular having clients requesting not to use condoms and not being able to find condoms may be further indicators of not having control over their work environment condom negotiation skills and availability are two critical service needs for fews and should be top priorities for future programming limitations of this study include the following first causal inferences were not possible due to the crosssectional study design second all measures were selfreported which means that there may be biases that may lead to both underreporting and overreporting of certain variables cultural norms around sexuality and sexual practices in cambodia suggest that information about sexual behaviors may be underreported efforts were made to reduce these biases including study procedures that ensured confidentiality including deidentifiable information and interviews conducted in confidential locations third the sample may not be representative of all fews in cambodia data were collected only from fews in the capital city and a large province where the sahacom a comprehensive communitybased project aiming to improve sexual reproductive health of fews has been implemented by khana therefore participants had an existing link to services the levels of sexual and reproductive health risks and outcomes reported in this study may therefore represent a more optimistic view than in other areas of cambodia conclusions in conclusions fews in this study experience high levels of psychological distress which likely stems from both past negative experiences and current working conditions women with higher psychological distress are at higher risk for poor health outcomes including attempted suicide substance use and engagement in risky sexual behaviors for women that are experiencing psychological distress programming should specifically address substance use condom negotiation and availability and suicide risk abbreviations aces adverse childhood experiences aids acquired immune deficiency syndrome aor adjusted odds ratio ci confidence interval fews female entertainment workers fsws female sex workers ghq general health questionnaire hiv human immunodeficiency virus sahacom sustainable action against hiv and aids in communities sd standard deviation stis sexually transmitted infections ptsd posttraumatic stress disorder competing interests the authors declare that they have no competing interests

background in cambodia there has been an increase in entertainment work as a result of the breakdown of the traditional brothelbased sex industry presenting new challenges to addressing the health issues and needs of people working in the entertainment industry this study aims to identify factors associated with psychological distress among female entertainment workers fews in cambodia methods a twostage cluster sampling method was used to randomly select 657 fews from entertainment establishments in phnom penh and siem reap in april and may 2014 for interviews using a structured questionnaire psychological distress was measured using the general health questionnaire ghq12 and multivariate logistic regression analysis was conducted results almost half of fews 432 had a higher level of psychological distress ghq12 3 while 195 reported having suicidal thoughts and 73 reported having attempted to commit suicide in the past 3 months controlling for confounding factors women with a higher level of psychological distress were significantly more likely to rate their overall health aor 188 95 ci 120 to 294 and quality of life aor 239 95 ci 147 to 387 as poor they were also significantly more likely to have suicidal ideation aor 241 95 ci 145 to 376 rate their hiv risk as higher than the general population aor 048 95 ci 031 to 074 have been forced to drink at work aor 177 95 ci 119 to 262 have had clients requesting not to use a condom aor 348 95 ci 114 to 1062 be not able to find condoms when they needed it aor 064 95 ci 045 to 093 have had a family member who said hurtful things to them during childhood aor 184 95 ci 124 to 275 and have had a parent or guardian who had been physically abused aor 193 95 ci 134 to 282 conclusions fews in cambodia experience high levels of psychological distress which likely stems from both past negative experiences and current working conditions for women that are experiencing psychological distress intervention programs aimed at improving mental health should specifically address substance use condom availability and negotiation skills and suicide risk

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background between 2018 and 2030 if present trends hold 150 million girls will be married before reaching 18 years of age the majority of these early marriages occur in south asia and sub saharan africa 1 early marriage is a violation of human rights compromises physical and mental health and heightens social disadvantage for girls 2 3 4 widespread recognition of these risks and the incorporation of early marriage as a sustainable development goal target have catalyzed efforts to accelerate decline in early marriage through prevention programming in regions of high prevalence 56 some of the more successful prevention efforts thus far have included conditional and unconditional cash transfers to keep girls enrolled in school and reduce the likelihood of early marriage 4 6 7 8 9 while incentivization programming has seen shortterm success in reducing rates of early marriage in several programs 7810 there is concern that this approach does not directly consider the socially embedded pressures promoting early marriage in girls which are rooted in the lesser societal value and diminished opportunity of girls relative to boys across cultural contexts 61112 additionally this strategy does not directly engage or consider the voice and choice of girls in the early marriage decisionmaking process consequently the sustained effectiveness of such programs is uncertain without changes in societally ubiquitous gender power imbalances and shifts in the marital decisionmaking autonomy of girls 101314 an alternative approach emphasizes community and schoolbased programs which have shown promise in the field and may have a better chance of addressing the underlying norms that perpetuate early marriage than a more shortterm resourcefocused intervention 5815 integrated into many of these prevention efforts is a focus on girlfocused empowerment programming which can be effective when implemented in tandem with more multipronged approaches 61416 investigating girls voice and choice in the context of early marriage is vital to understanding early marriage decisionmaking pathways 13 a substantial body of research shows that the most socially vulnerable girls are concurrently at greatest risk of early marriage 4111718 vulnerabilities to early marriage are most acute at the intersection of social and gender norms that encourage early and high fertility and result in unequal access to female education and employment the majority of studies of early marriage presume that girls have little to no voice or choice in the decision to marry this is reflected in prevention program designs that cater to the parents or to the community to create behavior change 6 however there is growing evidence that girls voice and choice may hold significant influence over decisionmaking 131619 older adolescent girls may be able to utilize voice and choice more successfully than younger adolescents 2021 and it is important to consider that this autonomy may be used to facilitate early marriage as well as delay or cancel marriage the decisionmaking power of the girl child has been inadequately considered and it is an essential component to understand in efforts to lessen early marriage there is little quantitative or qualitative research to guide understanding of the potential power girls hold over the decision to get married or not get married this study offers a qualitative exploration of how girls and their marital decisionmakers initiate negotiate and finalize decisions on early marriage using semistructured interviews from participants in ethiopia and india where prevalence of early marriage is 40 and 27 respectively 2223 this study aims to map the pathway of marital decisionmaking and identify the underlying reasons leading to the decision to marry as a minor or to delay or cancel proposed early marriage theoretical framework this research is informed by the theoretical underpinnings of psychological empowerment and resiliency theory psychological empowerment addresses its eponymous construct at the cognitive level with a focus on psychological strengths to create change in ones life fig 1 theoretical framework to explore psychological strengths and resiliency among girls regarding marriage circumstances in a context of cultural and structural influences that may restrict that change 24 resiliency theory also considers factors that can precipitate an individuals capacity to create change in hisher life in a context of social and structural restrictions or stressors recognizing individual skills and social assetsresources as well as psychological strengthsempowerment as mechanisms through which individuals particularly adolescents can disrupt neutralize or resist harmful behaviors or practices 25 26 27 and reduce physical and mental health risks 25 26 27 28 29 we applied this framework to explore how resiliency indicators affect marital decisionmaking in contexts where child marriage is normative methods study design and sampling data were drawn from a crosssectional qualitative study undertaken in 2014 to assess marital decisionmaking in the context of communities receiving early marriage prevention interventions in oromia ethiopia and jharkhand india study design has been described elsewhere 30 but briefly a convenience sample of participants was identified and recruited by programs across both sites for participation in a onetime semistructured inperson interview regarding experiences with early marriage and the program fiftyeight interviews were subsequently excluded due to data quality concerns participants were girls and young women who participated in the oromia development association comprehensive adolescentyouth sexual and reproductive health project or project regional initiative for safe sexual health by todays adolescents and received a marriage proposal when they were under 18 years of age and up to three of their marital decisionmakers all girls had participated in oda or project rishta and were identified via listings andor recommendations from program staff eligible girls were those who were either a married prior to age 18 or b were able to delay or cancel their proposed marriage as a minor during their interviews girls were asked to identify up to three people who were most influential in making the decision to proceed with delay or cancel a planned early marriage these decisionmakers were subsequently approached for fig 2 summary of selection process for interviews from ethiopia and india included in this analysis individual semistructured interviews the analysis presented here focuses on the 205 participants who discussed marital decisionmaking interviewee ages are presented in fiveyear groups to ensure anonymity study setting while the national prevalence of child marriage in ethiopia is 40 in oromia 48 of girls aged 2024 are married by the age of 18 oromia is majority rural 21 of 1519 year olds are pregnanthave already given birth and 52 of women have no formal education 2331 the region is predominantly muslim data were collected in rural areas in which oda a teacherled program initiated in 1993 aimed at reducing early marriage and promoting sexual and reproductive health via schoolbased delivery is operational in addition to srh education oda supports girls school retention and linkages to health extension workers as well as offering vocational training and linkages to a governmentsupported girls savings program oda is implemented across 248 communities in oromia and supported by the oromia development association and the david and lucile packard foundation in india while the national prevalence of early marriage is 27 38 of women aged 2024 living in jharkhand are married by age 18 2232 this prevalence increases to 44 in rural areas which encompass threequarters of the state 3233 more than one in ten 1519 year old girls in jharkhand are pregnant or have given birth and 41 of women are illiterate 22 jharkhand is majority hindu 34 project rishta builds on research supporting srh education in youth 35 36 37 and trains communitybased peer educators to facilitate discussions on early marriage prevention srh as well as supporting school retention and vocational skills training rishtas target populations are male and female youths who are engaged via mixedsex groups trusted adults support and reinforce the education messaging conveyed in these group sessions the program implemented in 32 villages in jharkhand began in 2001 and is supported by the tata steel rural development society and the david and lucile packard foundation data collection interviews were conducted by local female research staff trained in qualitative data collection and not affiliated with the programs informed consent was obtained from all interviewees prior to interview interviews approximately 60 min in length were conducted in settings of the participants choice and in a private location when possible assessed topics included participants knowledge attitudes and perceptions of early marriage and adolescent motherhood marital decisionmaking and program activities and their perceptions thereof all interviews were audiotaped and subsequently deidentified translated and transcribed for analysis by trained research staff in the respective countries data analysis data were analyzed using a latent content analysis approach to code and organize data into domains themes and subthemes 38 three trained coders reviewed 20 of interviews to identify domains and key themes from the interviews subsequently each interview was doublecoded by two trained coders using atlasti 7510 intercoder reliability was assessed via periodic checks using cohens kappa 09 themes identified iteratively via the coding process were reviewed discussed and agreed upon by the research team all interviews were then recoded with these new themes subthemes were also generated for some larger themes a concept mapping heuristic was used to explore relationships within themes 39 generated themes and subthemes were then considered through the lens of our theoretical framework ethical and safety considerations as noted above informed consent was obtained from all interviewees prior to interview original data collection was designed and managed by public health international and all data collection procedures were approved by the public health international institutional review board local ethical approval was provided by the oromia health bureau in ethiopia in india the local data collection senior research staff completed nih ethical certification trainings and trained all interviewers secondary analysis of deidentified data was granted irb exemption by the institutional review board of the university of california san diego results sample characteristics girl participants retained in these analyses had median ages of 1419 years with a range of 1323 the majority of girls whose early marriages were delayedcancelled in both countries were students at the time of interview while the majority of those who married as minors were housewives education levels were similar within each study setting with most ethiopian girls reporting primary school as the highest level attended indian girls most commonly reported secondary education as the highest level attended nearly all ethiopian girl participants were muslim in india girls whose early marriages were delayedcancelled were predominantly hindu and girls who were married as minors were most commonly sarna followed by hindu the median age at marriage was the same for girls married as minors in both settings while the median age of proposal for girls whose early marriages were delayedcancelled was younger in ethiopia than india decisionmakers ranged in median age from 27 to 39 in both countries decisionmakers for girls whose early marriages were delayedcancelled tended to have higher levels of education than decisionmakers for girls who married as minors the majority religion for each group of decisionmakers was similar to the girls in their respective groups with ethiopian decisionmakers being majority muslim indian decisionmakers were majority sarna and hindu the number of male vs female decisionmakers was relatively even in all groups except for ethiopian girls whose early marriages were delayedcancelled where decisionmakers were predominantly male interviewed decisionmakers for girls who married as minors were generally the parents in ethiopia and the husband and mother in india among girls whose early marriage was delayedcancelled key decisionmakers were for the communitybased rishta had higher numbers of parents and for the schoolbased oda program were primarily teachers social and structural constraints and stressors for early marriage social norms marital decisionmakers emphasized that social norms sustain the practice of early marriage with indicators of readiness for marriage based more on signs of puberty though less commonly mentioned marital norms were also reinforced by the lack of opportunities and pathways for unmarried girls and women which led some respondents to question the utility of education in a context of perceived limitations my father decided i should marry because he believed that education takes one nowhere he said if educated students come back and put pressure upon family they go nowhere therefore she must marry my mother also said the same thing i was not happy with the decision girl married as a minor muslim age 1519 ethiopia id 0101030305 while marital norms supportive of early marriage were commonly expressed by parents and elders peers were also important in the perpetuation of these norms she wasnt thinking of getting married at first there were her friends who got married earlier and divorced the mothers of other girls whose daughters got married and other friends convinced her to get married she believed them and accepted the request but we heard before the wedding and made her change her mind female decisionmaker for girl whose early marriage was delayedcancelled muslim age 2529 ethiopia id 010202227 legal sanctions against early marriage bear little cost relative to social sanctions against delayed or cancelled marriage some decisionmakers in ethiopia noted legal restrictions as a reason to prevent or delay an early marriage the effectiveness of these laws was mixed and in some cases penalties associated with legal transgressions were themselves identified as deterrents from seeking legal help in delaying or cancelling marriage indian participants indicated that law had little to no effect on practice what you are talking about laws when girls dont get married later or when you have to pay more dowry at later ages then no police and society comes to support you female decisionmaker for girl married as a minor sarna age 3034 india id w4i1s my parents and my teachers wanted to cancel the marriage with the help of kebele a subdistrict administrative division managers and other legal bodies they took me to the woreda district office and asked me whether it was my interest to marry or not i told them that it was my interest and i said my age is 18 years old though i was 14 years old then they let me go and i got married girl married as a minor muslim age 1519 ethiopia id 0102030310 the elders came to our home talked with my parents then my parents told me that i was going to get married… i know marriage under 18 is not allowable and punishable too but i didnt take my case to the court because i did not have the chance to do that plus my parents would be liable for this and i did not want my parents to get angry with me and go to jail girl married as a minor muslim age 1519 ethiopia id 0102030312 loss of a parent exacerbates risk for early marriage girls who lived in families where a parent had died or was otherwise incapacitated particularly a father or where their family situation was unstable in some other way had heightened vulnerability for early marriage as they were often perceived as a burden or risk in their natal families once married girls who had previously been viewed as a risk could be redefined as a protective asset for their families emphasizing the importance of each union from a family as well as individual context my father passed away when i was in 9th grade…… he was a drug addict… my mother got me married after my father passed away my husband and i live in my mothers house…… it was important for me to be married as we did not have any male member in our house after my fathers death girl married as a minor hindu age 1519 india id w21mp she told me that she wanted to get married to solve my problem since her father is sick we do not have someone to farm our land so i also wanted a solution to my problem and i decided to proceed with her marriage because of our problems we decided it though we like learning female decisionmaker for girl married as minor muslim age 3034 ethiopia id 010204429 initiation of early marriage initiation of early marriage begins outside of the girl and her family marital initiation is the stage in which there is discussion regarding whether a girl should or may wish to marry initiation of marital planning for a girl was almost never initiated by the girl herself most often it was those outside the immediate family who approached the family or the girl to begin marital discussions in ethiopia the most commonly mentioned initiators of early marriage proposals were the potential grooms or the potential grooms families traditional practices on the part of a grooms family rendered girls parents more vulnerable to social pressures to move forward with a marriage proposal and the girl was commonly informed after the decision to move forward with a marriage was already made according to our culture the boys family takes chat a mild plant stimulant to the girls family and asks for their daughter in marriage then those elders have respect and the girls family cannot say no so the girl is given by her parents male decisionmaker for girl whose early marriage was delayed cancelled muslim age 2529 ethiopia id 010202254 in india girls extended family were the predominant initiators of early marriage often expressing concern to the parents that the girl would be socially stigmatized by remaining unmarried or by indicating that a good match was available and that other good matches might not follow as the girl aged in this context mothers often were guiding the decision and again girls were not engaged in the decisionmaking my husbands brother insisted that i get x married he said that the villagers are making all sorts of remarks some of my relatives tried to dissuade us but my brotherinlaw told them not to interfere i had no option but to get her married female decisionmaker for girl married as a minor hindu age 4044 india id w13i1p a relative had brought the proposal my family liked this boy because he is wellsettled belongs to good family and is educated also my inlaws have a lot of agriculture land and a proper house moreover my husband is young and doesnt consume alcohol considering all these factors he was chosen as a groom for me…girl married as a minor hindu age 1519 india id w22ms girl engagement in early marriage decisionmaking typically involves planned elopement in both ethiopia and india when girls were engaged in marital decisionmaking it was more commonly in a context where a prospective groom approached the girl often without her parents knowledge peer pressures in these circumstances could bolster girls intention of proceeding with marriage but this greater control over decisionmaking also offered facilitated opportunities for external intervention it was he himself who told me at first but later after he came to realize he couldnt win me alone he repeatedly sent many friends of his until i was convinced girl married as a minor muslim age 2024 ethiopia id 0102030316 i was in 8 th grade when we met for the first time in a mela fair he proposed and said that he liked me and i should come with him and he will take me away with him i told him that i wanted to continue my studies but he said that he will let me continue with my studies after marriage…finally i came with him from a mela without telling anybody girl married as a minor santalli age 2024 india id w16mr in these contexts girls exhibited selfefficacy to move forward with support from grooms despite potential disapproval from parents the motivation for these couplelevel decisions was often described as a desire to marry based on love a finding discussed further in the subsequent negotiation stage girls resilience against marital initiation came from social support in familyelderinitiated marriages but from self in groominitiated marriages as girls were often not involved in the initiation of early marriage social resources and support rather than girls individuallevel psychological empowerment and skills were the primary mechanism of resistance this is not to say that girls themselves were not vocally resistant but it was the instrumental social support from parents particularly fathers that more often forestalled a forthcoming proposal fathers valuation of and support for girls continued education was the most commonly noted reason for halting proposals lots of proposals used to come but i was never informed about them nobody discussed them with me i would hear my grandfather arguing with my father my grandfather often used to try to convince my father to accept proposals but my father wanted me to study and said he will not let me marry before i am 18 girl whose early marriage was delayedcancelled sarna age 2024 india id w26ms the marriage was first proposed by the boys family… after the marriage proposal from the boys family i also took time to discuss the proposal with my family and relatives… we reached an agreement about her right to pursue her education before actual marriage male decisionmaker for girl whose early marriage was delayedcancelled muslim age 5559 ethiopia id 010102204 in contexts of groomled proposals and lack of parental or other elder involvement girls psychological empowerment and skills to voice their choice against marriage were more effective he did not propose directly to me he told another person and then they came to me and always harassed me on my way to school then i told them that i do not want to marry i even insulted them he told his friends he told me that he wanted to marry me because an educated girl knows how to cook in a clean manner girl whose early marriage was delayedcancelled muslim age 1014 ethiopia id 0102010120 proposal negotiation familyelder involvement with early marriage initiation typically excluded girls from decisionmaking at negotiation once early marriage discussions were initiated proposal negotiation began including discussions of outcome groom selection and timing of marriage as with initiation negotiation often excluded girls when elders or extended family were involved in india parents particularly mothers guided acceptance of proposals for their daughters often out of fear that future marital prospects might be limited if you delay marriage then you may not get a good match… i was scared she may start looking overage and ugly so as soon as we got a good proposal we accepted it i dont think there is any loss in marrying early if you get a good match female decisionmaker for girl married as a minor sarna age 3034 india id w4i1s social pressure was also manifested in cultural proposal practices bordering on coercion in ethiopia in particular participants described the difficulties in breaking the pathway for marriage proposals in which the brides family and surrounding community were incentivized to endorse the union most of the people in the community were supportive of the marriage if you go to their house and chew chat the second time you go there they have already finished everything the guy will give them cash to convince the girl they will try to convince you to get married and if they like the guy you will think that you should like him as well he gives you money and you know you should not ignore the gift then you end up saying yes to his proposal girl married as a minor muslim age 1519 ethiopia id 0102030317 girls engagement in early marriage negotiation typically followed groominitiated marriages that directly engaged girls when girls were in favor of early marriage they often used voice to persuade their families to allow proposed early marriages working to gain social support through a number of means including threat of family stigma as a consequence of elopement we cant influence her while she was telling us that she loved him and wanted to marry him in our culture you dont share your love affair with parents and parents also do not get involved nobody helped her in the decisionfemale decisionmaker for girl who married as a minor muslim age 4044 ethiopia id 010104403 she proposed to me and i agreed i even asked her to inform her family… i met her mother she was fine with our relationship but she asked me to leave before xs father arrived…it was only her father who wanted to cancel the marriage but after she came to my home her cousin convinced her father that it is better if she marries me than a situation where she eloped with me he got worried about the girls and the family reputation and later he agreed to the marriage male decisionmaker for girl married 18 sarna age 2024 india id w12i1d girls resistance to early marriage negotiation came largely from early marriage prevention program staff as social resourcessupport strengthening girls voice respondents in both countries spoke of the benefit of having an advocate outside of the traditional family and cultural circles of marital decisionmaking when negotiating the delay or cancellation of an early marriage proposal this external influence had the benefit of both defraying any adverse social repercussions that family members bucking social norms might incur as well as being seen as a source of valuable information on the adverse effects of early marriage in this study these were generally individuals from the early marriage prevention programs importantly their involvement helped girls voice their resistance to the marriage x first talked about the possibility of cancelling postponing the marriage she was not ready to marry at that time and wanted to study more she tried to speak to her mother but her mother didnt listen to her she then called me and asked me to talk to her mother i went to her place and convinced her mother to let her complete her education and then marry her fortunately her brother has also attended rishta project and was very supportive of her female decisionmaker for girl whose early marriage was delayedcancelled sarna age 3539 india id w52i1s …when she discussed with her aunt she finally refused the marriage and when they asked her why she replied that she did not want to marry a person she didnt know and that she didnt want to marry at 14 when she wasnt able to convince her aunt we went together and convinced her… her uncle told me that if he was refusing the marriage he was going to be neglected from the society so he said that it was better if i spoke so i convinced them this way it has many challenges female decisionmaker for girl whose early marriage was delayedcancelled orthodox age 2529 ethiopia id 010102260 the role of an external influencer was not easy nor was their influence universal key decisionmakers coming from outside the family or traditional decisionmaking pathways described substantial social barriers to their involvement this participation which was noted as quite beneficial by some was also directly shunned by others as many parents and girls themselves asserted their right to make their own choices without pressure from others when i went to meet them they were very rude to me the brother was taunting and the mother did not listen to me she asked me if i would take responsibility for her daughter if she remained unmarried all her life i went to their home at least 56 times and slowly they started listening to me then i spent one day with her mother… she thought about the proposal and then cancelled it female decision maker for girl whose early marriage was delayed cancelled hindu age 3539 india id w48i1d in ethiopia where the early marriage intervention program was schoolbased several participants described early marriages that were initiated over the summer holidays to avoid intervention by the teachers we did not try to cancel or postpone the marriage because if we try to cancel or postpone the marriage we fear that she might go with him without my permission so i prefer to give her myself and no one supported her to cancel the marriage since it is summer season when the teachers were not around as a result many of the girls get married during summer season for fear of the teacher cancelling the marriage male decisionmaker for girl married as a minor muslim age 3539 ethiopia id 010204428 fathers were usually the final decisionmakers on a marriage particularly in cases where the marriage was initiated and negotiated with extended family elders or the grooms family justification for early marriage was most commonly that it was a good match and that a comparable match might not be subsequently available fear of no future marital prospects for a daughter was also a noted concern for parents unmarried female relatives offered a cautionary tale for girls and families girls largely acquiesced to the parents even if it was not their preference we got the proposal when she was 17 years old we had a fear that she will run away with someone or will opt for intercaste marriagewe were afraid that she might end up as her aunts who never got married we liked the boy he was from a good family he also did not drink alcoholi made the final decision on her marriage male decision maker for girl married as a minor sarna age 4044 india id w17i1d it was difficult because the decision was against my desire i was forced to accept the decision for i had no option you cannot deny the words of a father whatsoever girl married as a minor muslim age 1519 ethiopia id 0101030302 in india when mothers were the final decisionmaker it usually still involved convincing the father to agree with her position maintaining his role as final decisionmaker mothers rationales for early marriage were more likely to relate to reduced household burden once the daughter has married her father was opposed to the marriage because he wanted her to study more… my brother had brought a very good proposal so as soon as i received this proposal i accepted it my husband and inlaws did not agree with it even x was not ready for marriage but gradually i could convince everyone female decisionmaker for girl married as a minor sarna age 3034 india id w4i1s whether fathers mothers or parents together made the final decision girls were often not included in some cases the marriages appeared to be forced the boys family sent elders to my family to request the marriage so my family heard about my marriage first i only heard on the wedding day my husband also did not know about our marriage at first so both of us were forced to marry because of the push from our parents girl married as a minor muslim age 1519 ethiopia id 0101030302 my mother decided about my marriage i was very upset and i cried a lot but she didnt listen to me… my husband is good his family is good but i still feel i am not ready to take responsibility of child and family girl married as a minor hindu age 1519 india id w22ms fathers were most commonly the final decisionmaker to delaycancel a marriage usually without girl involvement as with final decisionmaking in favor of early marriage in india fathers were most likely to be the final decisionmaker in the cancellation or postponement of early marriage in ethiopia while fathers were important decisionmakers ethiopian girls whose marriages were delayedcancelled often served as their own final decisionmakers most commonly delayed marriage was desired to support girls completion of their education we usually discuss the marriage within the family and everyone in the family is of the view that the girl should be given an opportunity to study as much she wants the decision is not really tough for us as we are financially strong enough to support our daughter we decided to postpone the marriage till a decent age of 20 or so because early marriage means more responsibility for girls our daughters were not very well trained in household chores and so if married early they would have not been able to manage their house or husband female decisionmaker for girl whose early marriage was delayedcancelled hindu age 3539 india id w40i1s while she came back from school to her home elders were enjoying by chewing chat in her familys house saying that the marriage was in her interest as soon as she saw them she turned back to her school and told her teachers about the issue then her teachers asked her interest whether she wanted to continue education or marry she responded that her interest is continuing with her education next her teacher took her to the kebele office immediately one person observed the situation and went to the elders and told them that they were going to be arrested then the elders disappeared it was she who made the final decision male decisionmaker for girl whose early marriage was delayedcancelled muslim age 3539 ethiopia id 010202245 often however parents were more covert with their efforts to delay their daughters marriage for fear it could compromise her future marital prospects we the adults of the family decided to postpone the marriage usually when the proposal comes we let the boys family come to our house and see the girl but later we dont respond to them actually we want her to complete her graduation first and then only get married we cannot say directly no to the boys family or else the proposals would stop coming in female decisionmaker for girl whose early marriage was delayedcancelled hindu age 3539 india id w40i1s cancellations of early marriage were not without risk as highlighted by a number of participants as described in earlier quotes cancellations could compromise future marital prospects they also reflected poorly on the family of the groom and thus risked retaliation these concerns were particularly noted in ethiopia where ritualistic aspects of marital agreements created greater social pressures and social ramifications for families the marriage was not postponed to another time it was cancelled for the grooms family the decision has social impact there is a question why they were refused when they proposed the marriage because they want to strengthen their relationship with the girls family female decisionmaker for girl whose early marriage was delayedcancelled orthodox age 2529 ethiopia id 010102260 girls empowerment in final decisionmaking on early marriage involved marriage without parental consent girls and their grooms were final decisionmakers on early marriage in cases of elopements or love marriages in which they selfselected each other sometimes without parental approval in some cases these girlor coupledriven unions were implemented explicitly to circumvent parental selection of partners this was the most direct demonstration of autonomy seen in marital decisionmaking when i was around 12 i met him in a village mela festival then i met him after a year or so and spoke to him too… my family told me that they will hit me if i see any boy at such a young age i got scared and told him to take me away i put pressure on him by saying that my family would get me married then we eloped i must have been 13 at that time girl married as a minor sarna female age 1519 india id w9mp my daughter was extremely happy about the decision and she was so eager to leave with him as a father i was not in a position to accept and agree to the marriage but the elderly people in our compound and our neighbors advised me just to agree and accept it since the two decided previously to marry to each other and to live together male decisionmaker for girl married as a minor muslim age 5054 ethiopia id 010204424 love was a reason given for early marriage in both countries and while it was noted both in girls who did and who did not marry early it was substantially more prevalent among girls who married early the marriage proposal was presented through her because she loved the guy it is difficult to stop someone who loved somebody female decisionmaker for girl married as a minor muslim age 4044 ethiopia id 010104403 …it was bit difficult to run away because my father wanted me to study more but i cant help it i knew he is meant for me my family agreed to it after a while anyway they did not have a choice they did not agree initially as my husband belongs to a poor family… i discussed it with my boyfriend we decided to elope and marry girl married as a minor sarna age 2024 india id w5 this minority of girls who were instrumental in driving their early marriage also discussed actions they would take if prevented from marrying whom and when they wanted these actions were often very serious in nature she went to the mans home without asking any permission and when we said dont get married now she said she would commit suicide otherwise… her decision to commit suicide forced us to say okay to the marriage we took her back home once but she went back to her husbands we took her again she went back for the second time finally we made the decision to let her go because i love her i chose her living female decisionmaker for girl married as a minor muslim age 3539 ethiopia id 010204432 discussion this qualitative analysis used the lens of resiliency and psychological empowerment of girls to explore early marriage decisionmaking in ethiopia and india and revealed both key patterns and substantial variation in pathways and people involved across contexts the stressors that maintain early marriage are relatively clear and consistent as seen in quantitative studies key social and cultural components underpin the early marriage decisionmaking process 6144041 social pressure and cultural marital norms were influential in both countries particularly for older decisionmakers and were hard to break as perceived repercussions were high and longlasting vulnerability to early marriage was further increased when these norms were compounded with social inequities or with the loss of a parent legal sanctions were not as impactful as social sanctions in influencing marital decisions these findings echo a large body of research supporting the importance of norms in relation to early marriage and emphasizing the importance of a systemic rather than a more direct incentivization approach 414 40 41 42 within the complex structures sustaining the practice of early marriage the impact of girls voice choice and successful realization of marital intent was inconstant underscoring the importance of individual community and structural factors influencing early marriage decisionmaking and the norms that underpin that process resiliency and empowerment of girls did not necessarily lead to delayed or cancelled marriage the early marriage decisionmaking process from initiation to negotiation to final decisionmaking demonstrates that in these contexts initiation of early marriage proposals largely came from outside the nuclear family and reached the parents for negotiation without the girls involvement resistance came through social support from parents or at negotiation from early marriage prevention program staff girls voice and selfefficacy and skills to alter these circumstances was limited especially once social traditions had been observed at the same time when parents identified a good match in the context of the early marriageenabling stressors discussed above they were generally working to support the girls interests as they best knew how early marriage prevention programs were influential at the negotiation stage which was most open to extrafamilial influences but were not as meaningful in the initiation stage this is likely because proposals were often rooted in cultural traditions involving elders and family that summarily excluded girls themselves when girls are unaware of marital initiation discussions they cannot engage programmatic support by the time a final decision was made generally by the parents intervention and advocacy were at greater disadvantage the utility of programmatic support in the negotiation phase is limited by availability highlighting an important consideration regarding the ongoing sustainability of this external influencedriven approach namely that social resources offered by early marriage prevention programs likely have to be sustained and available to girls whenever needed girls in families with greater social and financial instability particularly the underage girls whose father or other caregiver had died or those living in poverty were more vulnerable to early marriage a finding consistent with prior research 18 subsequent to those marriages these girls were sometimes repositioned from a position of liability to that of an asset to the family the prevention of early marriage is critical from a health human rights and development perspective 4 and programs and advocates aiming to delay early marriage should be cognizant that there are circumstances where benefits of early marriage may clearly outweigh disadvantages in the view of the family and community 56 they will therefore need to work to address these contextual factors rather than assuming that delayed marriage is always the obvious and right thing to do or that early marriage happens only because families and communities arent aware of alternative sociocultural norms pathways to prevention the funneling of key actors along early marriage decision making pathways offers key insights in the ethiopian sample the pathway to delay or cancellation of proposed early marriage was paved with the efforts of the girls themselves teachers and parents girls voice choice and agency was seen throughout this process girls who were married early had their decisionmaking pathways more heavily influenced by elders but still often had input themselves through the negotiation and final decisionmaking steps of the process in the indian sample girls voice was noted as they most frequently were the first objectors to early marriage but their choice and agency were diminished as evidenced by their less prominent role in the negotiation and final decisionmaking stages girls whose marriages were delayedcancelled often had heavy involvement from their parents particularly their fathers who served as the most common final decisionmakers for both early and delayedcancelled early marriages the decisionmaking processes of girls who were married early were more heavily influenced by other family members and elders girls demonstrated marital decisionmaking empowermentvoice choice and agencywere most apparent when prospective grooms initiated proposals in this pathway girls were often able to block or facilitate proposals if they so chose highlighting that early marriage may not always be unwilling and that the proposed bride andor groom may be active proponents rather than passive or resistant participants romanticizing elopement and the autonomy to choose ones own partner reinforces this operationalization of empowerment but at a cost these couplelevel decision making pathways had the potential to leave girls more vulnerable due to the lack of adult engagement and did sometimes end in early marriage indeed in some cases early marriage was accelerated in order to retain decisionmaking at the couple rather than parental or family level while perhaps atypical in these communities this operationalization of voice choice and agency in favor of early marriage is not a circumstance that can be ignored from the perspective of inclusive and empowering prevention programming 43 a necessary component of empowerment is the enabling of full autonomy of choice and action not that which has been restricted within acceptable parameters structural early marriage interventions that involve education protective legal environments and norm shifts particularly regarding the status of girls and the acceptability of adolescent sexuality can help to create an enabling environment for informed decisionmaking but cannot proscriptively make those decisions for the girls in question coupleled decisionmaking in favor of early marriage may also be indicative of one of the few ways that adolescents can engage in physical relationships in contexts of restrictive adolescent sexuality in many settings particularly in asia premarital sex is culturally unacceptable and carries substantial risk and stigma 4445 this norm is borne out in the current study settings in jharkhand the median ages at marriage and sexual debut for women are the same in oromia these events are very similar in median age though sexual debut slightly precedes marriage for women 23 early marriage prevention programs must recognize the cultural biological and social factors influencing adolescent sexuality in order to address this driver of early marriage limitations this study must be interpreted in the context of several limitations first qualitative interviews were drawn from purposively sampled program participants living in rural districts of oromia ethiopia and jharkhand india and cannot be inferred to be representative of broader national or regional populations data quality was compromised in 58 of the original 265 interviews however 207 interviews representing all eight groups of interviewees were retained for analysis finally interviews were subject to recall and social desirability bias implications for intervention research policy understanding how these different players and pathways interact in local contexts throughout the process of early marriage decisionmaking offers a concrete entrypoint for prevention efforts with several key implications first there is value to building the voice choice and agency of girls with regards to marital decisionmaking but the resulting empowerment will have little tangible impact in the absence of resiliencysupporting social support and resources adolescents have substantially less power in general than authority figures in their families and communities and thus will have difficulty operationalizing empowerment without targeted support this support appears most relevant to the negotiation phase of early marriage decisionmaking an important window in which program educators were able to influence families parental engagement in early marriage prevention programs remained critical as they were the most consistently mentioned actors involved across the entire early marriage decisionmaking continuum and did not always agree on desired outcomes programs that involve both parents may thus be better equipped to support advocacy for the delay or cancellation of planned early marriages in this sample girls rarely had complete autonomy in marital decisionmaking thus while programs focused exclusively on empowering girls are important and almost certainly have direct and indirect benefits not captured in the present analysis they are likely of inadequate scope to have a profound effect on reducing levels of early marriage relatedly the options for adolescent girls in these contexts need to be expanded beyond marriage or education pitting these two outcomes against one another presumes that all girls want to stay in school and that they do not want relationships with boys a presumption not supported by the elopement narratives described in this paper without additional viable avenues for adolescent girls to pursue empowering these girls is unlikely to reach the maximum potential benefit using only a two sizes fits all approach as seen in this and other research girls need an enabling environment that provides opportunities beyond marriage 1043 the benefits of delaying marriage are more likely to be meaningful to families if they can clearly see the pathways through which delayed marriage would yield better opportunities for their daughters underage girls who have impaired social or economic status appear particularly disenfranchised from early marriage decisionmaking and may require particular attention and support this analysis demonstrates the complexity and breadth of players and pathways involved in early marriage decisionmaking qualitative work such as this is a necessary foundation to understanding early marriage as a process rather than simply as an outcome but it also a resourceintensive endeavor not feasible for broad application researchers policy makers and program implementers would benefit from the creation of a standardized quantitative measure of early marriage decisionmaking that considers not only the stages of decisionmaking and key players outlined in this paper but also the level of voice choice and agency that minor girls are able to exercise conclusion early marriage is too often described as an outcome or a prevalence in fact for the girls and their families who are most impacted by this practice early marriage is a process understanding that process both in terms of the major decisionmaking stages and key players as well as the social and cultural environments that influence those processes will enable those working to eliminate early marriage to more appropriately and comprehensively target and tailor their interventions to maximum effect choice voice and agency are critical elements with which to curtail early marriage but are inadequate when implemented in the absence of enabling environments supportive of a greater breadth of safe and viable decisionmaking pathways and outcomes beyond marriage some researchers have found that empowering girls in a context of extreme disempowerment can have unintended harmful consequences 104647 this work underlines the importance of recognizing the broad and complex circumstances that influence early marriage decisionmaking it is only when this global concern is addressed holistically that lasting change will be achieved endnotes 1 all interviews are labelled with the following components early marriage status of girl decisionmakers gender and relationship to girl religion age country and interview identification number additional file authors contributions lm ej km and ar contributed to the conception and design of the analysis ej and km conducted the data analysis with input from lm and ar yb and as contributed to the acquisition and interpretation of data lm drafted the manuscript which was subsequently critically revised and edited by all authors all authors gave final approval for the manuscript to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved consent for publication not applicable competing interests lm ej km and ar declare that they have no competing interests yb and as are employees of the david and lucile packard foundation which supported this analysis and the data collection and programs described herein their input into analyses and objective interpretation of findings for this manuscript were not influenced by their employment with the funding institution

background early marriage of girls marriage 18 years is a pervasive abuse of rights that compromises maternal and child health the common conceptualization of this practice as an outcome undermines the nuanced and sometimes protracted decisionmaking process of whom and when to marry methods this paper uses qualitative data from semistructured interviews with females aged 1323 years who participated in child marriage prevention programs and either married early or cancelledpostponed early marriage and their key marital decisionmakers in oromia ethiopia n 105 and jharkhand india n 100 results social norms and the loss of a parent were stressors sustaining early marriage across contexts participants described three stages of early marriage initiation negotiation and final decisionmaking girls were infrequently involved in the initiation of early marriage proposals though their decisionmaking autonomy was greater in groominitiated proposals the negotiation phase was most open to extrafamilial influences such as early marriage prevention program staff and teachers across settings fathers were the most important final decisionmakers conclusions the breadth and number of individual and social influences involved in marital decisionmaking in these settings means that effective early marriage prevention efforts must involve girls families and communities while underlying norms need to be addressed programs should also engage and enable the choice voice and agency of girls empowerment was important in this sample but generally required additional social resources and support to have impact girls with greater social vulnerability such as those without a male caretaker had more compromised voice choice and agency with regards to early marriage understanding early marriage decisionmaking as a process rather than an endpoint will better equip programs and policies that aim to eliminate early marriage to address the underlying norms that perpetuate this practice and is an important lens through which to support the health and human rights of women and girls globally

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introduction the united nations sustainable development goals and the united nations convention on the rights of persons with disabilities advocate for the inclusion of persons with disabilities in all spheres of society the south african constitution asserts that persons with disabilities must have equal access to education employment basic services and reasonable accommodation however relatively marginal changes have been made within societal structures to effectively provide equal access to persons with disabilities the understanding of disability in this article is aligned to the un convention on the rights of persons with disabilities and the international classification of functioning definition of disability which steps away from the impairmentfocused deficit model of disability therefore i define disability as historically pwd have been marginalised globally and are currently still experiencing marginalisation despite various international and governmental policies and treaties that advocate for their rights they are prevented from accessing healthcare education and economic opportunities on an equal basis with other members of society they are often viewed through a medical deficit lens that identifies whatever impairment they have as the reason pwd are excluded from accessing equal opportunities and in some instances they are even perceived as being a negative influence on society the world report on disability stated that the african region holds a higher number of persons with disabilities that are moderate to severe most of whom are in the younger generation under 60 years of age adding to this complexity is the high prevalence of poverty and governments incapacity to adequately address these challenges in a manner that facilitates access to opportunities and the inclusion of youth with disabilities within society which often leads to further marginalisation of this vulnerable group there is a need to create inclusive structures that support equal access to opportunities for youth with disabilities in society this article presents key considerations for creating an inclusive framework within societal structures by facilitating access to performing arts opportunities for youth with disabilities in south africa this has the potential to support personal growth and social inclusion of youth with disabilities within south africa historical divisions along racial and gendered lines created major social divisions during the apartheid era people with disabilities were further oppressed and had limited access to public spaces and opportunities the patterns of inequality created during apartheid contributed to structural and systemic barriers to inclusion for pwd which are still experienced to date persons with disabilities currently make up more than 75 of the nations population but have seen little change in the area of access for instance to opportunities for economic and social participation many of this vulnerable sector live in urban townships or rural areas where services are especially difficult to access and despite the progressive element of the constitution have been left behind this includes youths with disabilities young people under the age of 35 make up 66 of the south african population these young people generally encounter a lot of structural and attitudinal challenges within society and are even more challenged by societal and systemic barriers youth with disabilities require adequate care medical equipment and rehabilitation accessible buildings and transport as well as emotional support from family members and care workers these factors are single or synergistic satisfiers of human needs for social and economic development and would facilitate better inclusion of youths with disabilities in our society the national youth policy outlines a youth development strategy for south africa creating an avenue for youth with disabilities to be represented and included in development opportunities through the ministry for rural development and land reform this is equally aimed at enhancing the use of local resources to facilitate inclusive opportunities for youth with disabilities artscape and the many programmes it offers for young people and youths with disabilities for instance is one such local resource that can be used to facilitate the inclusion of youths with disabilities the present situation highlighted here has informed this study this article reports on participant narratives on key aspects of inclusion which can facilitate access to opportunities and social inclusion of youth with disabilities this emerged from a study that explored how interaction with the performing arts may facilitate the social and economic inclusion of youth with disabilities by fleshing out their marginalised position within the context of a postapartheid south african theoretical framework and methodology of the study this section briefly explains the theoretical framework methodology and research design followed in the collection organisation and analysis of data and positions the researcher within the study there are four theoretical frameworks that guided the study feminist ethics of care which advocates for a collective approach to address injustices based on gender models of disability assisted exploration of the definitions of disability holistically intersectionality which supported the identification of the multiple intersecting systems of oppression emanating from my participants experiences history and context and human scale development which asserts that all fundamental human needs are culturally and historically constant and that humans share a deep need to satisfy themselves research has shown that the lived experience of disability is mostly different for male and female people and the researcher as a female person with a disability has lived experience of this difference the gaze that is cast upon the female disabled body often breeds further marginalisation and sometimes even violence in addition the study has an emancipatory element of opening up marginalised spaces and the discourses within open access those spaces therefore as advocated by the feminist ethics of care and intersectionality it became relevant to ensure that the voices of young women with disabilities were equally represented to explore how these young women experienced disability and access within their own contexts it was aimed at bringing out the female narratives and the intersecting locations of their lives to repudiate assertions and assumptions based on their gender andor gender roles and to address the challenge of inadequate role models for women with disabilities this emancipatory strategy was carried through in the methodology by ensuring representation across both men and women during recruitment and sampling the theories used in this study intersectionality ubuntu feminist ethics of care and the maxneef theory of needs satisfaction all validate the given facts they include empathetic understanding and care interconnectedness and interrelatedness participation solidarity community and reciprocal commitment to each others wellbeing these are the foundational concepts of this study as youth with disabilities seek a space of recognition of shared humanity caring social relationships and equal participation on all levels of beingness study context methodology and research design study participants were recruited from the cape flats which is an area located between the city centre of cape town and cape town international airport the cape flats consists of predominantly black townships coloured ghettoes and shantytowns this area was the place to which most black people were relocated and migrant labourers also settled there after other areas were declared whites only during apartheid and the group areas act was passed this area was commonly referred to as the dumping ground which is characterised by high levels of poverty and historically the marginalisation of youth methodology a qualitative research approach was adopted using a critical ethnographic research design in essence critical ethnography explores the culture community and daily circumstances of participants considering what is currently occurring and possibilities for the future boylorn and orbe asserted that critical ethnographers are interested in the politics of positionality where researchers expose their own privileges in addition to their marginalisations and take responsibility for their subjective lenses through reflexivity critical ethnographers aim to explore understand and interpret the dynamics within a group identifying past and present patterns of injustice that may have consequences for current life experiences finlay agrees with richardsons evaluation of ethnographic research both authors advocate offering both scientific as well as literary aspects of research and using diverse ways to present ethnographic research both argue that reflection on the personal emotive narrative is as important to evoke as the socalled positivist typical rendition of what scientific knowledge is or should be thus the researcher is located as a potential influence within the research process and must therefore explore any subjective bias they may have as a black woman with a disability and as someone from a historically marginalised community i am aware of my closeness to the data therefore reflexivity is a valuable tool for me to evoke the literary aspect of my research and draw from critical ethnography and my positionality in this study to confront previous practices of discrimination and to address this by ensuring an authentic representation of the voice of my study participants that aligns to their subjective experiences of access to opportunities as youth with disabilities therefore i position myself in the next section positioning the researcher i am a woman of mixed race from a rural town wellington south africa i contracted polio when i was three months old this is because i grew up in a segregated community under apartheid hence the white clinic refused to administer the polio drops to me as a mixedrace person this is because mixedrace people could not receive vaccination in any clinic segregated for white people only my family was poor and struggled socioeconomically however plenty of love care and support was given to us as we grew up this love and care however could not protect me from the systemic discrimination and marginalisation i experienced growing up as a 54yearold woman today i have firsthand knowledge of the impact of these deficit systems on the growth and development of young people i had neither access to a special needs school nor to accessible transportation as there was no public transportation for persons of mixed race in the rural town of wellington for example when considering university in the 1980s i enthusiastically sent an application to the music faculty of one of the top higher education institutions in the country with a very excellent art programme to be an opera singer only to be turned down because of my impairment they stated that they had no space for a disabled opera singer this is one reason that the theory of intersectionality is important to me and even more so as it has truly played out in my own life despite this setback i was taught to push and not give up by my family and to trust in my own will and capacity to succeed so i learnt to improve my understanding of people and the arts especially how to contribute to resilience for youth with and without disabilities in my community and at all levels of society encouraging them to pursue their dreams my experiences have further strengthened my understanding of the key issues of access that persons with disabilities have to face i align with shahs assertion that young people are active social agents able to articulate their own experiences and express their views this has informed the work i do with youths with disabilities open access therefore in this study whilst narrating my marginalisation i equally acknowledge my methodological privilege as a disabled researcher i am positioned as a research tool to consciously elicit the narratives and experiences of inclusion by these young pwds this supported me in identifying current barriers inherited from the history of systemic oppression and collectively identifying sustainable contextual ways to address them and to facilitate inclusion study population the study population are youth with disabilities who have attended at least one or more events at the artscape theatre this sample also includes youth with disabilities from historically disadvantaged communities in cape town youth comprise young people between the ages of 18 and 35 years of age so this guided the categorisation of youths participant sampling inclusion criteria a purposive sampling strategy was used for the study all participants were youth aged between 18 and 35 years as defined by south africas youth commission act they selfidentified as male or female and had selfdescribed sensory mobility mental or psychosocial disabilities they are bilingual as the researcher needed to conduct the interviews in both english and the participants spoken local language recruitment strategy the recruitment of participants occurred across three different settings and there were three focus groups and one interview held as described here the cape flats comprises poor disadvantaged black and mixedrace communities in the western cape province south africa i contacted disability organisations because as a person with a disability i am familiar with these organisations and their work with youth with disabilities the organisations approached are womans achievement network for people with disabilities they work with young women with disabilities unmute a professional dance company working with young pwd stigting vir bemagtiging deur afrikaans a cultural organisation that brings young pwd to the theatre and attendees of the unmute artsability festival these organisations then contacted their members in the cape flats area and informed them about the research they gave my contact details to people who were interested some had access to phones and called or sent a message to me i then called them back to explain further next because some of the interested youth did not have phones i organised transport with the help of these nongovernmental organisations to collect all the youths who were interested in participating and bring them to a venue where we met and i clarified and explained more about the research answered all their questions and sought their consent which they gave by signing the consent forms two additional groups from training institutions were also identified and invited because students from these schools often attend performances at artscape the consent form was sent to the principal who gave it to the learners and those who were interested contacted me therefore the three groups and one individual recruited were as follows • six learners from the tertiary training college for the deaf attending a theatre performance as audience members • seven grade 12 learners from a learners with special education needs school who attended a production of an afrikaans setwork 3 and were facilitated by the ngo sba • six disadvantaged community youth • one individual interview which was conducted with a performer with a disability at artscape focus group sessions were held with the three groups the focus group discussion was specifically chosen over individual interviews because of the vulnerability of these young pwds being in a group meant that they could support each other to speak and share stories in this way peer support was encouraged in addition because of the isolation they often experience as a result of their disability they had few social interactions therefore being in a focus group meant that they could socialise whilst participating in the research data were also collected through a document analysis from the artscape universal access and design task teams database and two indepth individual interviews with the black disabled female performer in addition three focus groups were conducted with a total of 19 participants from the schools and the youth with disabilities from disadvantaged communities the researchers reflective journaling of the research process was used as secondary data to support analysis data management and analysis all data transcripts and field notes used in this research are not in the public domain all data were stored by the researcher on a passwordprotected computer file and it will be stored for five years as stipulated by the university of cape town data analysis began with the transcription of all digitally recorded data creswell suggested that in reading through data and gaining familiarity one can start the process of understanding it thematic analysis as described by bowen and braun and clarke was used to identify recurring themes and patterns in the focus group open access interactions specifically focusing on a critical ethnographic concern with patterns of social injustice braun and clarke viewed thematic analysis as a flexible tool for research which can potentially provide a rich and detailed yet complex account of data thematic analysis enables researchers to make sense of data in accordance with their specific focus and within a broader methodological framework the researcher established a manual coding system to identify recurring themes and patterns emerging from the data and effectively categorise responses bowen 2009 ethical considerations ethical approval to conduct the study was obtained from the human research ethics committee of the faculty of health sciences university of cape town participants were informed about the nature of the study and that it is a lowrisk study but any risk that arises will be minimised they were handed informative handouts and given opportunities to ask questions for clarification through questionandanswer sessions before giving consent they were informed that could withdraw at any time without any negative consequences data were anonymised to protect the identity of study participants and enhance confidentiality all participants were treated with dignity and respect the following section presents participant narratives of inclusion what they identify as key factors that they believe facilitate their access to opportunities and the challenges they experience as young people for inclusion findings interactive spaces and social connections participants identified the very important need to be able to fit into society as much as any other young person as a basic right they should be able to exercise the capacity to go out and be socially included is a necessity and one which they believe begins with the creation of opportunities and having receptive attitudes positive identity and agency these opportunities should be facilitated by consciously supporting youth with disabilities to grow their identity and sense of self one participant stated that this positive sense of self helps to negate a history of marginalisation and contribute to a sense of agency for young people i f you sit and wait for funding to come to you you are going to wait forever i was placed in that position where i was forced to start creating opportunities for myself to be able to have work parental support was highlighted by participants as a critical factor that contributes to their confidence and agency one participant from the focus group who frequently attends events and performances stated here that the values she carries were instilled by her parents whilst another participant from the training institution felt inspired to support youth to respond to challenges and build their selfagency by creating an organisation the values that they instilled were always that you dont wait for someone to hand something to you you go out and you do something for yourself then it kicked back home that i need to start an organisation for pwds but mainly focus on the young people at school because growing up with these challenges they need to face the challenges thats out there because accepting the fact that you are disabled you cant go there and you cant do this because of all these stumbling blocks its not gonna help its just keeping you back participants believe that support systems which contribute to agencybuilding for youth with disabilities will motivate and inspire them to realise they can reach higher and aim for more as exemplified by a deaf learner in high school the school learners were all white people or mixed race the deaf open access white learners were more affluent and clearly voiced their career aspirations my goal is to go and study next year it programming and then i would like to be a speaker in parliament and to work within the deaf community contrary to this many of the mixed race and black learners were from disadvantaged low socioeconomic communities they were hesitant to discuss their career options and some aspired to become skilled labourers whilst others looked towards a career in the arts although they still battled with a lack of confidence and fear a jewellerymaker although my main thing i want to do is to build houses okay now i sing a lot i go out to concerts i perform in churches i perform in all that other stuff but now i do less i dont know what happened but i suddenly lost confidence and suddenly now i have so much fear that i never had when i was a teenager but when it comes to music ive got much confidence in it on the other hand some barriers to inclusion and access to opportunities were also identified by participants some of the challenges stemmed from personal challenges and some were systemic and structural but all impacted on their capacity to access opportunities in one way or another mobility challenges the youth with disabilities who participated in the study identified certain challenges that were barriers to inclusion public transportation was identified as a major challenge to accessing opportunities and inclusive spaces the challenge was not only related to accessing transportation but even getting to the taxi rank from their houses was often very challenging and strenuous due to the condition of the public roads within their environment the challenge is i cant go alone to take the transport because of the roads and also its not wheelchair friendly for me to be able to travel alone i need to take a bus and golden arrow sometimes they have an issue with me using the bus then they want me to pay for the wheelchair and for myself as well access to resources another dimension that emerged from the findings of the study based on participant narratives pointed to the impact of south africas history on youth with disabilities in terms of resources required for access one alternative to problematic public transportation is privately owned transportation most of the white youth could access privately owned transportation while black and mixedrace youth struggled to do so currently we are busy building up my own car so that i will be able to drive here on my own next semester participants also felt that the impact of this resource constraint even influenced their experience of inclusive spaces this is because even when structures are inclusive many people who manage these spaces lack disability sensitivity and therefore often do not realise the need for additional accommodation for persons with disabilities striving to fit in some challenges were specific to certain groups of participants the learners from the high school for the deaf and the tertiary institute for the deaf struggled with the anxiety of having to engage with hearing people within systems and structures that are more exclusive rather than inclusive of them although some deaf people have acquired the skills to interact in a world more attuned to hearing people the anxiety also occurred at a personal level when we are now outside working and done with our education how are we going to communicate with the others with the hearing brandon student theatre attendee fg1 some deaf people can mix with hearing people and then some deaf people do not know the skills and techniques required to communicate with hearing people so some deaf people can do it they can do it but i just do not know how to communicate with the hearing despite these highlighted challenges participants believe that inclusive structures and systems as well as their deeply held aspirations are necessary for successful inclusion the need to prove themselves despite these challenges is reflected in the following statement no i think that one is a person showing the world that even if i am disabled let me show them that i can do it you can do it now i can showcase my hobby to a lot of people and that will also contribute into changing the mindsets of the people who think that disability is also in the head because when they see you they like agh you stupid you know you cant think … open access im going to showcase the work that im doing my hobby because designing is a hobby for me im not a professional designer ive never been to designing school but i love fashion and people should see that we can also dress up like make up like girly stuff and we like the neatness you know its not just about agh we dressed because we have to get dressed you know there is more to us than what meets the eye the given section expands on the outcomes of the study further synthesising the key findings above to highlight the key tenets of an inclusive framework from the participant narratives above the given quote by one of the youths with disabilities reflects the general sentiment expressed by the study participants in consideration of a more disabilityinclusive framework that consciously takes note of context and holistic engagement of the youth with disabilities within society there are certain key factors that have emerged from participant narratives that would contribute positively to support a contextually relevant and appropriate disabilityinclusive framework within the south african context these factors can be synthesised into three main areas discussed here discussion enhancement of personal capacity agency and skills development for youth with disabilities there is a worldwide crisis of youth unemployment including in south africa critical to this is the social isolation and marginalisation of youth with disabilities who consist of a staggering 71 of people who are unemployed in south africa the south african government identified youth with disabilities as a vulnerable group and a target population for redressal more than a decade ago but they still do not constitute a government priority in a study that explored the availability of work transition programmes for youth with disabilities in south africa authors identified inadequate research that focuses on this group with little data disaggregated to highlight information on their status these include the supportive and inclusive structures needed to enable them to realise their aspirations even more critical is the need to hear from the youth themselves in support of their agency and autonomy research that involves youth with disabilities which elicits their narratives is key to challenging societal normative assumptions that impact negatively on the creation of inclusive structures to integrate youth with disabilities into all aspects of society this supports the given quote by a participant who insists that one of their biggest challenges is that society is largely unfamiliar with and distanced from the realities of youth with disabilities this can be addressed through focused research to elicit their narratives supporting and empowering families to inform sustainable change disability is not only a physiological societal and systemic issue but also a deeply personal and emotive issue participants in this study speak about a personal internal resilience that exists making them strive to learn new skills to sustain themselves despite all odds families are key support systems for resilience and participants often referred to the role their families or parents played in their lives helping them to become resilient the communitybased rehabilitation framework recognises the key and pivotal role which families play when it comes to the inclusion of pwd community based rehabilitation advocates for the ongoing inclusion of families and communities in programmes planned for pwd as part of an inclusive framework although they battle fear anxiety social stereotyping and oftentimes a lack of selfesteem and confidence related to social interactions due to longterm stigmatisation and abuse that they experience there is a resolve to keep aspiring supported by their families daly conducted an integrated literature review of resilience in the fields of psychology sociology philosophy education and nursing one of the key outcomes of the study is that closeness to resources is vital to inclusion and builds resilient wellbeing for youth with disabilities the family is one such resource which must be utilized through empowering families as a tool for inclusion of youth with disabilities effecting systemic and structural changes for inclusion of youth with disabilities one of the needs identified by youth with disabilities is the relevance of systemic and structural accommodation of their needs closely linked to this is the importance of general disability sensitivity or awareness to support societal inclusion and access to opportunities disability awareness would speak to negative attitudes suffered by youth with disabilities even within inclusive spaces as described by a participant here disability is a multidimensional concept and the lived experience of it is influenced by systematic differences based on gender disability race or ethnicity and socioeconomic status the historical imbalances imposed by south africas past constitute certain barriers for these young people youth with disabilities from historically disadvantaged communities perceive their white counterparts as having more access to resources that facilitate their inclusion into society than they do this is especially seen in the area of accessible transportation which is key to accessing opportunities for schooling employment recreation places of worship and many other spaces of advancement an inclusive disability framework must cater for all areas of youth development physical cognitive social emotional wellbeing and learning a holistic approach that accounts for all aspects of their humanity is key to the development of selfdetermination which is a significant predictor of postschool success for youth with disabilities one sees the impact of the legacy and history of south africas apartheid on the selfdetermination and aspirations of youth with disabilities who come from communities that were subjugated during this era redress is an important factor to inform the inclusion of youth with disabilities there is a need to recognise that all youth with disabilities are not equal in terms of resources to access opportunities and their sense of self therefore systems must be set up to further assist youth with disabilities from disadvantaged communities to be able to dream and achieve daly agrees with the summation above stating that proximity to resources is key to accessing opportunities and building resilience of the youth with disabilities to facilitate inclusion related to a sense of self meiring focuses on embodiment within the southern african context he emphasises the importance of taking cognisance of the bodily experiences of black people in south africa and having a deep sensitivity for the profound impact of colonialism apartheid and even postapartheid on the black body this is applicable to youth with disabilities and there should therefore be a conscious move to address this deficit within an inclusive framework meiring discussed the notion of embodied sensing stating that all people have the challenge of sometimes being unable to make meaning of their worlds with words we all embody this sense of meaning even when we cannot explain it with words one challenge is that pwds are often told by ablebodied people who they are and what to believe about themselves meanwhile even if they cannot speak or are hesitant to speak youth with disabilities are much more than their disabled bodies they also have this embodied sense of themselves and should be given the right to define for themselves who they want to be harnessing this sense of embodiment to inform the inclusion of youth with disabilities is critical it will entail creating unhurried spaces of dialogue and authentic nonthreatening engagement that allows for selfexpression as this study has shown artscape and ngos who bring youth with disabilities to interact and attend performances can provide a space for these facilitated dialogues conclusion globally and in south africa youth with disabilities are not prioritised as they should be by governments although youth constitute most of the working population in south africa they still experience marginalisation and minimal access to opportunities at systemic and personal levels in part because of south africas past injustices and a general lack of disability sensitivity within society from the narratives of inclusion that emanated from youth with disabilities in this study three main factors that contribute to an inclusive framework have been identified they are enhancement of personal capacity agency and skills development for youth with disabilities supporting and empowering families to inform sustainable change and effecting systemic and structural changes for the inclusion of youth with disabilities study implications finally based on the research presented this article makes the following recommendations • promotion of societal systems and structures that actively facilitate the inclusion of youth with disabilities accessibility to all public spaces should be ensured including places of social interaction to facilitate inclusion • adopt inclusive practices at all levels of society with government academia and ngos providing disability sensitivity programmes and training so that even when inclusive structures are built managers of these structures are aware of the need for further accommodation as required • the experience of youth with disabilities from disadvantaged communities specifically is informed by race gender socioeconomic and spatial divisions of an apartheid legacy therefore in the interest of equity additional government funding and training must be made available to support these youth and their families to access equal opportunities at par with their peers in order to facilitate inclusion data availability data sharing is not applicable to this article as no new data were created or analysed in this study authors contributions the author declares that she is the sole author of this article disclaimer the views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any affiliated agency of the author

he loss or elimination of opportunities to take part in the life of the community equitably with others which is encountered by persons having physical sensory psychological developmental learning neurological or other impairments which may be permanent temporary or episodic in nature thereby causing activity limitations and participation restrictions within the mainstream society stats sa 201113 the given definition clearly heralds the need to address this loss of opportunities for people with disabilities pwds the south african constitution asserts that persons with disabilities must have equal access to opportunities in society however the realisation of this mandate has remained a challenge there is a need to create contextually relevant inclusive structures that support equal access to opportunities for persons with disabilities in society objectives this article reflects on and highlights key considerations for an inclusive framework that facilitates access to opportunities for youth with disabilities in south africa which emanated from a study that explored how ongoing interaction with the performing arts can facilitate social and economic inclusion of youths with disabilitiesthe study adopted a qualitative research approach using critical ethnography primary data were obtained from three focus groups with a total of 20 youth with disabilities who have attended performance events as well as an indepth interview with a disabled performerthe facilitation of access to equal opportunities for youth with disabilities must occur at a multidimensional level involving both personal and systemic changes and levels of support complex barriers linked to the apartheid legacy also exist some of which include access to resources and reduced selfdetermination whilst positive factors such as internal resilience and skills development function as promising predictors of inclusioncontextually relevant disabilityinclusive structures in south africa must confront and address how youths with disabilities are uniquely impacted in present times by south africas historythe voices of youths with disabilities make a key contribution as their experiences must inform these inclusive structures which have the potential to enhance access to equal opportunities for them at both personal and systemic levels

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background care homes in england have been disproportionately affected by the covid19 pandemic with high rates of infection and excess mortality in residents 12 and staff members 34 in may 2020 care home residents accounted for nearly 54 of all covid19 related deaths 5 while there was substantial evidence in terms of epidemiological data of the adverse impact of covid19 on care homes residents 1 6 7 8 there was much less evidence into the impact of the pandemic on employees their working practices and their attitudes towards the prospective vaccination 910 with increasing knowledge of how infections spread and the role of asymptomatic transmission 11 ways of working in care homes changed in response to the pandemic 12 for example since june 2020 care home residents and staff have been offered regular testing for sarscov2 using nasopharyngeal swabs which has made it easier for care homes to detect control and reduce the spread of covid19 infection 13 a range of public health disease control measures have been introduced such as visitor restrictions 91415 however the most significant intervention to reduce infection and its transmission was the development of vaccines 16 17 18 19 in the uk care home staff and residents were prioritised for vaccination against covid19 which began with the pfizer vaccine on december 8th 2020 and was shortly followed by approval of the astrazeneca vaccine 20 the majority of residents received a twodose primary vaccine course and have subsequently received a third dose however at the time of this study uptake of vaccination by care home workers was variable 1021 and this was of significant public health concern the department of health and social care reported that sages social care working group advice was that 80 of staff and 90 of residents needed to have had their first dose of the vaccine to provide a minimum level of protection against outbreaks of covid19 however only 53 of homes with residents over 65 in england were meeting this threshold in the first few months of the vaccine rollout by april 2021 the staff vaccination rate was below 80 in 89 local authority areas more than half and all 32 london boroughs and there were 27 local authority areas with a staff vaccination rate below 70 based on dhsc reports 21 22 23 in terms of the broader covid19 cases and public health measures in the uk right before this study was conducted in 2021 the percentage of positive tests in the population was 65 as reported by public health england 24 by midapril 2021 the recorded number of deaths for the general population related to covid19 had reached over 127000 in the uk 25 at the time of the study there was no lockdown and no government restrictions on nonhousehold mixing however personal protective behaviours such as mask wearing social distancing and the use of hand sanitizers were still strongly recommended requirements for traveling abroad included proof of vaccination status in addition to a negative pcr test a more detailed timeline of the uk lockdowns and restrictions can be found at insti tutef orgov ernme nt org uk sites defau lt files timel inelockd ownweb pdf several studies in different countries have been conducted to explore concerns and population characteristics associated with vaccination uptake 26 27 28 a high number of studies focused on examining vaccination intentions and behaviour in the general public to control virus transmission 29 30 31 32 some research has also examined healthcare workers vaccine attitudes and behaviours as healthcare workers play a key role in limiting the covid19 transmission impact by acting as a vector for potential transmission between patients or care facilities by role modelling for preventive behaviours and also helping vaccinate others 33 34 35 36 however very few studies examined vaccination attitudes and beliefs of social care workers working in care homes particularly in the uk context 101737 those that focused on care homes found that care home workers attitudes towards covid19 vaccination varied with some studies reporting that the majority of social care staff had no reservations to get vaccinated immediately while others reported that staff wanted to wait or were reluctant to accept the vaccine 3103738 however these studies did not use a theoryinformed approach to study vaccine uptake vaccination is a form of human behaviour which could thus be understood through application of behavioural science the benefits of drawing on theory to investigate influences on behaviour and inform intervention development are widely recognised and emphasised in best practice intervention development and evaluation frameworks such as the mrc complex interventions guidance 3940 behavioural science theories provide explicit statements regarding processes hypothesised to regulate behaviour which can in turn be used to explain and predict behaviours using theory enables drawing from and contributing to the wider literature and evidencebase on what influences behaviour change 41 one simple integrated model of behaviour change is the comb model which posits that in order for a desired behaviour to occur the individual must have the capability opportunity and motivation to do so 42 the model has been used to explain potential influences on a number of protective behaviours related to covid19 including vaccination uptake in the general population 43 44 45 46 the comb model is mapped to frameworks such as the behaviour change wheel and behaviour change techniques taxonomy 4748 to suggest which types of behaviour change strategies are more likely to be effective in addressing influences within different domains of capability opportunity and motivation this facilitates more systematic and transparent stepwise progression from understanding factors influencing behaviour to generating concrete suggestions for how best to change the behaviour of interest however to our knowledge behavioural science frameworks have not been applied to investigate factors influencing covid19 vaccination uptake in social care professionals working in care home settings and to generate suggestions for intervention approaches to support vaccine uptake in this context therefore the present study aimed to apply behavioural science frameworks to identify influences on covid19 vaccination uptake amongst staff working in uk care homes identifying such influences is a prerequisite for addressing vaccine hesitancy and enabling future preparedness consequently a secondary aim was to generate recommendations for potential behaviour change intervention strategies to support vaccine uptake the specific research questions addressed were which factors related to capability opportunity and motivation influence care home staff s decision to be vaccinated against covid19 which behaviour change strategies could help target key reported influences in order to reduce vaccine hesitancy and support uptake methods study design this study was part of the larger vivaldi programme of research 1649 which collected and analysed epidemiological data on the impact the covid19 in care homes residents and staff in england vivaldi included a larger number of participants from a wide selection of care homes this study was part of a qualitative explorative work package which recruited staff employed in care homes that were already participating in vivaldi participants and recruitment three large care home providers in england who were participating in the vivaldi study 49 were asked to identify care homes that might be willing to take part in interviews within participating care homes a purposive sampling approach was used to sample individual staff to take part we aimed for the overall sample to include representation of as wide a range of staff roles in care homes as possible this included both staff working in clinical roles as well as managers and nonclinical staff participants were offered an incentive of £50 for taking part procedure all interviews were conducted between march and june 2021 by four researchers care home managers were asked to circulate a study advert and information sheet to staff staff who were potentially interested in participating were contacted by a study researcher to arrange an interview at a time and date that was of convenience to them participants provided consent to the study by signing a consent form prior to commencing the interview and in one occasion one participant provided verbal consent at the start of the interview and completed and retuned the consent form to researchers after the interview all interviews were conducted virtually using microsoft teams audiorecordings of interviews were transcribed verbatim and anonymised so that no individual or care home facility could be identified from the data interview guide data were collected using a semistructured interview guide this paper only reports the data extracted from the transcripts related to vaccine uptake the findings from other sections of the interview guided will be reported elsewhere the section on vaccine uptake included questions on whether or not participants had taken the vaccine and factors potentially influencing the decision to be vaccinated or not these questions were structured around the domains of the comb model whereby the topic guide included at least one question per domain in order to ensure the broad range of potential influences on vaccine uptake were being considered questions were asked in an open nonleading way with unstructured flexible followon prompts used as necessary to further unpack participants initial responses data analysis a combined inductive thematic and deductive framework analysis approach was conducted 5051 we first conducted an inductive thematic analysis to generate themes from the transcripts regarding perceived barriers and enablers to vaccination uptake without being restricted by the predefined domains of the comb model meaningful chunks of text were extracted from transcripts and descriptive summaries generated these descriptive summaries were added to a data extraction matrix alongside supporting and illustrative quotes similar in content summaries were then grouped together and an inductive theme label was generated themes were classified as either a barrier to vaccination uptake an enabler to uptake or a mixed influence inductively generated themes were then subsequently deductively coded to the domains of the comb model they were judged to best represent four researchers independently coded all interviews one researcher coded the majority of interviews while the other researchers coded the remaining interviews additionally seven out of the twenty interviews were coded by two researchers all researchers had training and experience in qualitative data analysis any disagreements regarding coding were discussed in consensus meetings with the involved coders until an agreement on the coding was reached following identification of barriers and enablers we consulted the behaviour change wheel 47 to generate suggestions for potential interventions to address reported barriers and enablers and increase vaccine uptake in this context the behaviour change wheel summarises 9 broad intervention strategies for changing behaviour these are further broken down into component behaviour change techniques defined as the active ingredients of a behaviour change intervention 48 p82 the behaviour change technique taxonomy v1 defines 93 unique bcts both the behaviour change wheel and behaviour change technique taxonomy have been mapped to comb in matrices which suggest which types of intervention strategies are likely to be more relevant and effective in addressing barriers and enablers within capability opportunity and motivation 5253 we consulted these matrices to identify potential interventions to increase vaccine uptake based on our mapping of presently identified barriers and enablers to the domains of comb ethics ethical approval for this study was granted by the university college london ethics committee results theme 1 informationseeking strategies about vaccination overall this theme was an enabler to vaccination uptake we asked participants what kind of information sources they have used to make their decision on vaccination the majority of participants said that they either conducted their own research or based their decision to get vaccinated on information shown in the media provided by the government and local hospital communications or through discussions with colleagues and close friendsfamily a few participants mentioned social media as an informational source but there was awareness that this was a potential source of misleading information which had contributed to many colleagues decisions to refuse vaccination most participants felt very well informed about vaccination for covid19 some discussed whether to be vaccinated with friends andor family members and other care home colleagues particularly when vaccination rollout started most participants expressed positive attitudes towards vaccination and some mentioned that they were also having the seasonal flu vaccine to protect the residents in this context previous flu vaccination acted as a familiarisation factor for exposure to vaccine information as a result these individuals reported that they did not require a lot of additional information for the covid19 vaccine it was acknowledged that the care home employers supplied a lot of information to their employees which had facilitated their decisionmaking many participants mentioned that they valued the information and support that they received through the care home employer some participants mentioned that a confidential helpline was also set up by their provider through which care home staff could get information on vaccinations if requested overall participants felt very wellinformed and none of them expressed concern about not having had sufficient information available as illustrated in this quote i dont think theres a lot else that can be done really because the information is all there theres opportunity if youre not sure to check with your own gps or to chat to others… theme 2 ease of access to vaccination having to travel to another location to get vaccinated was identified as a barrier to vaccine uptake as this made some individuals reluctant to receive the vaccine initially however ease of access and convenience of vaccination when vaccination was later offered in the care home was reported as an enabler the following quote highlights this point we had a doctors surgery came out one day and vaccinated all of us we were all in a line some staff members were also taken by surprise with how quickly they were offered the vaccine and reported that they needed more time to carefully consider and process all the available information before taking the decision to be vaccinated theme 3 social interactions and support from managers colleagues and care home organisations social influences in terms of participants social network and interactions were identified as a key enabler to vaccine uptake when participants were asked about the attitudes of their friends and family members towards vaccination they all indicated that they had very similar attitudes to their own as this quote shows yeah like i said my husband told me i was stupid if i didnt have it yes and my oldest son you know he he said he was going to have it when he gets the chance you know itll be a little while yet so yeah they were glad i think some of the main reported reasons for why people who were initially reluctant to accept the vaccine changed their mind included seeing that others who had been vaccinated remained well over time and positive and reassuring conversations with colleagues and with their employers all participants mentioned that their care home employers encouraged their staff to accept the vaccination but none reported that this resulted in them feeling pressured by their employers to do so table 1 furthermore all participants explicitly emphasised the importance of giving people the opportunity to make up their own minds participants were asked about their interactions and discussions with colleagues who decided not to be vaccinated as indicated in the following quote theyre worried about it so but i know i spoke to one of them and they are thinking about it now because like everyones been okay i think theyre just worried again about side effects they all reported encouraging colleagues to be vaccinated and to change their minds but also emphasised that they respected their colleagues views and their right to choose whether to be vaccinated or not all participants valued the fact that staff had autonomy to make their own decision they suggested that their vaccine hesitant colleagues should receive more information and that it was important to listen to and address their concerns they felt that pointing out that vaccination was a way back to normality was likely to have a positive influence on staff s decision to be vaccinated theme 4 beliefs about benefits of vaccination participants clearly stated their perceived benefits of vaccination which motivated them to get the vaccine reasons provided for accepting the vaccination included staff own protection protection of residents and close contactsfamily members leading by example and doing what is for the greater good allowing more freedom in the future and believing that it was the only way back to normality some participants mentioned that being vaccinated would allow them to travel abroad which was particularly important to those staff members who were originally from a different country as stated in the following quote well first of all i think its my duty secondly i want to go back to country and im hoping that were going to have a vaccination passport which says there you go ive had my vaccinations please let me back to country all participants stated they were not doing anything different following vaccination the same protective measures were still in place post vaccination and continued to be followed they also stated that they would also adhere to the same personal protective measures in their lives outside of the work environment in contrast when asked about their unvaccinated colleagues attitudes and beliefs participants believed that concerns about potential sideeffects was the main reason for their colleagues hesitancy in particular those with preexisting health conditions were especially concerned and apprehensive that vaccines might not have been tested appropriately and that the evidence base was still very limited some participants perceived that vaccine hesitancy could be more prevalent among different ethnic and religious communities who have limited trust in public health authorities as reported in this quote the ones that i found were sceptical for their ethnicity was some of our black colleagues you know our colleagues from africa i dont know why they werent keen its funny the indian individuals that we have they were really keen to to go to hospital but the black africans werent that keen but the majority of them have had it now theme 5 emotional response to vaccination emotions represented a mixed influence on vaccine uptake many participants mentioned that they felt happy about getting the vaccination as indicated in this quote i was quite emotional about it i i felt quite i i actually felt im so lucky im so lucky that i can get this vaccination and i felt fortunate i felt very fortunate because i know theres people in other countries who are not being given this opportunity one participant even reported having cried out of relief for some others it was less emotional and they just felt they had to do what they had to do one participant mentioned feeling better about themselves after the vaccination some participants reported not having any particular emotional reaction to the vaccination mapping of identified barriers and enablers to proposed interventions table 2 presents the use of the behaviour change wheel and behaviour change technique taxonomy to select appropriate interventions based on the key components of the comb components as a basis for future policy recommendations we propose four intervention types and nine bcts to target individual knowledge motivation and emotional other interventions focus on increasing ease of access to vaccination centres and improving communication and promotion of vaccination by appointing a person in a leadership role to champion being vaccinated this role is to encourage staff to be vaccinated and to reduce any concerns about sideeffects vaccine safety and risks from having preexisting health conditions discussion we explored uk care home staff attitudes and behaviours towards the covid19 vaccine before the covid19 vaccine became mandatory in this work environment overall our findings are wellaligned with findings from previous studies on vaccination uptake key factors enabling vaccination uptake included willingness to protect themselves and vulnerable others 9 having an encouraging workplace and social network 1237 and the expectation of return to normality 54 concerns about the speed of vaccine development and approval lack of research for potential longterm effects and concerns about side effects and allergic reactions for specific health conditions were barriers linked to vaccine hesitancy 10172838 our study demonstrates the benefits of mapping the identified factors influencing the decisionmaking processes leading to vaccination acceptance or refusal in order to propose theoreticallyinformed strategies that could potentially increase vaccine uptake in care homes specifically our findings highlight the importance of capability opportunity and motivational influences on vaccine uptake for psychological capability there were no issues with understanding the pros and cons of vaccination to make an informed decision from the available information however some knowledge of vaccines can be from less scientifically robust sources such as social media suggesting educating staff on where to find trustworthy information is important 955 also a focus on educating about preexisting health conditions or concerns regarding fertility may improve the psychological capability of informing what is perceived as a a risky decision such as vaccination 10 for physical opportunity there were no real obstacles with getting the vaccine because after an initial period all vaccinations were taking place in the care homes nonetheless this highlights the importance of ensuring that vaccination is convenient and accessible in order to maximise uptake and future vaccination interventions need to be mindful of this for social opportunity seeking advice and information from family and friends and work colleagues was commonplace and had resulted in some colleagues who were initially reluctant to accept the vaccine to change their minds this suggests that social opportunity is an enabler that should be harnessed in future interventions with more emphasis on enabling conversations between colleagues and their managers within the ch context to understand concerns and fears of the consequences of those who are vaccine hesitant and how best to address these apprehensions 937 especially if a positive vaccine attitude is endorsed or modelled by a senior member of staff or someone who has a leadership role within the ch or from the wider healthcare community to promote the benefits of vaccination this can have a significant impact 263656 motivation was the most complex aspect of vaccine uptake in terms of reflective motivation most participants prioritised being vaccinated to protect themselves and others from covid19 because it was the right thing for the greater good and knowing that everybody getting vaccinated is the way back to normality therefore when targeting the beliefs of those who are vaccine hesitant it may be valuable for persuading that vaccines are safe and effective and the optimal way forward for managing covid19 longterm 26 as part of the educationbased strategies also target automatic motivation through enabling those who are vaccine hesitant to communicate their anxieties and have conversations about how best to reduce and overcome these concerns 1037 importantly our findings highlight the role of nonjudgmental positive peertopeer interactions in decision making and the need for public health authorities to address fears and safety concerns regarding the covid19 vaccine as a recently developed vaccine 54 strengths and limitations strengths of this study include providing evidence to address a research gap for an under researched population and context including a representative sample and using a theoretical framework for analysis of the data however an important limitation of this study is that we only interviewed individuals who had been vaccinated which limits our ability to draw inferences about barriers to vaccination beyond perceptions of those who had been vaccinated regarding the underlying reasons for vaccine hesitancy of those colleagues who had refused the vaccination although findings in our study related to barriers and enablers for the bame communities should be treated with caution as these are not necessarily the perspective from bame participants directly but rather participants reporting on their perceptions of their bame colleagues vaccine hesitancy among the bame communities has been welldocumented in other published evidence that aligns with our findings 625 58 59 60 policy implications and recommendations the behavioural analysis of the findings has guided the identification of theoreticallyinformed proposed interventions detailing the relevant bcts for implementation in the context of recurrent discussions regarding mandatory vaccination for health and social care employees when health crises arise 59 60 61 62 63 64 65 we propose theoryinformed implementation strategies which would foster vaccine confidence and encourage people to get vaccinated willingly 6667 mandatory vaccination for care home staff was introduced in england on 14 th june 2021 and although this increased vaccine coverage it also led a substantial minority of staff to leave the sector which exacerbated preexisting staff shortages 213760 this policy does not align with our findings as people emphasised how much they valued autonomy in their decisionmaking process the policy decision to mandate vaccination against covid19 in care home staff has now been reversed but given the importance of regular vaccination to maintain protection against covid19 there is an ongoing need for evidenceinformed strategies to increase vaccine uptake in this context our policy recommendations for the current and for future vaccination uptake and pandemic preparedness would be • providing staff with relevant material from a credible evidencebased source that outlines the facts around benefits and risk of getting the vaccination in order to allow an informed decision • providing easy access to vaccination • senior care home staff management should engage with staff about vaccinationfears of those hesitant to get vaccinated have to be taken seriously and addressed modelling the behaviour is also an impactful way to change negative attitudes and beliefs and lead by example • facilitating communication between staff on peer level in order to exchange views concerns and experiences regarding vaccination • staff from the bame community in particular could address concerns from their peers who are sceptical of the vaccination and lead by example conclusion overall our research participants were positive about getting vaccinated although they reported that some colleagues were hesitant to accept the vaccination we identified as enablers to vaccine uptake receiving adequate information material the opportunity to get vaccination relatively hasslefree having positive conversations with care home managers and other staff about any fears as well as the awareness that being vaccinated protects people around them and that it is a way back to normalcy the main barriers to getting vaccinated were fears of potential side effects and mistrust with regard to the development of the vaccinationespecially when these were magnified by respective misinformation in social media based on these findings we suggest that health and social care providers and policy makers should consider our suggested intervention strategies and care home managers employers and policy makers should facilitate open nonjudgmental discussions with care home workers who are vaccine hesitant to provide the opportunity to these members of staff to discuss their reasons for not getting the vaccine while also respectfully encouraging vaccination uptake • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from additional competing interests the authors declare no competing interests

background the covid19 pandemic disproportionately affected people living and working in uk care homes causing high mortality rates vaccinating staff members and residents is considered the most effective intervention to reduce infection and its transmission rates however uptake of the first dose of the covid19 vaccine in care homes was variable we sought to investigate factors influencing uptake of covid19 vaccination in care home staff to inform strategies to increase vaccination uptake and inform future preparedness methods twenty care home staff including managerial and administrative staff nurses healthcare practitioners and support staff from nine care homes across england participated in semistructured telephone interviews marchjune 2021 exploring attitudes towards the covid19 vaccine and factors influencing uptake we used thematic analysis to generate themes which were subsequently deductively mapped to the capability opportunity motivationbehaviour comb model the behavioural change wheel bcw was used to identify potential intervention strategies to address identified influencesenablers to vaccine uptake included the willingness to protect care home residents staff and familyfriends from infection and the belief that vaccination provided a way back to normality reflective motivation convenience of vaccination and access to accurate information physical opportunity and a supporting social environment around them favouring vaccination social opportunity barriers included fears about sideeffects automatic motivation a lack of trust due to the quick release of the vaccine reflective motivation and feeling pressurised to accept vaccination if mandatory automatic motivation we identified influences on covid19 vaccine uptake by care home staff that can inform the implementation of future vaccination programmes strategies likely to support uptake include information campaigns and facilitating communication between staff and managers to openly discuss concerns regarding possible vaccination side effects freedom of choice played an important role in the decision to be vaccinated suggesting that the decision to mandate vaccination may have unintended behavioural consequences

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introduction the coronavirus disease 2019 pandemic has created unprecedented disruptions of public health systems globally affecting people of all ages epidemiologic studies from multiple countries have reported that people over 60 years old are at substantially higher risk of severe covid19 disease than other age groups 1 2 3 notably although children are generally quite vulnerable to viral infections symptomatic covid19 had unexpectedly low prevalence in children and teenagers under 20 years old 1 2 3 4 during the early stages of the pandemic it was at first unclear if children were more likely to experience asymptomatic infections or simply have a lower infection rate populationwide screening conducted in iceland found no positive infections with sarscov2 the virus that causes covid19 among children under ten years old whereas people older than 10 years had a 08 positive infection rate 5 in the united states although population screening was not widely implemented the low asymptomatic rate in a representative pediatric population suggested evidence of low rates of infection with sarscov2 among american children 6 though the sarscov2 infection rate in this age group increased with school reopening the pediatric covid19 incidence remains low compared to the proportion of this age group in the general population 7 reasons for disparities in sarscov2 infection among age groups are unclear while differing immunological and physiological susceptibilities exist 89 children and adults also experience different levels of environmental exposure to sarscov2 that raise the risk of covid19 in adult populations due to differences in daily activities and behaviors 10 indicating that neighborhood environment might contribute to differences in covid19 incidence among children and adults in addition to the differing infection rates of covid19 across age groups the unequal distribution of covid19 cases in neighborhoods with different socioeconomic status has also been noted especially in us metropolitan areas 11 12 13 14 15 16 the neighborhood characteristics examined in those studies were identified using the american community survey a tool widely used in epidemiology to investigate disparities among adverse health outcomes 18 for each study researchers selected acs variables as representatives of arealevel ses then linked the selected variables to covid19 incidence through geographic units commonly zip code areas results of these studies suggested that neighborhoods marked by lower ses had relatively higher covid19 incidence one multicity study created an index of neighborhood disadvantage based on six neighborhood characteristics from the acs 14 epidemiological evidence of the link between exposure to lower ses neighborhood characteristics and multiple adverse health outcomes including covid19 has been inconsistent since different studies select different variables to represent neighborhood ses moreover given that covid19 is a new disease selecting neighborhood characteristics to study using traditional epidemiological approaches risks missing other neighborhood risks of covid19 disease which may not have been recognized a priori we considered that transmission of the sarscov2 virus and associated covid19 disease could be related to neighborhood characteristics not previously investigated and sought a novel approach to identify neighborhood characteristics important for further study the recent development of exposomebased approaches permits agnostic exploration of neighborhoodwide risk factors to diseases 1920 the neighborhoodwide association study framework inspired by the genomewide association study approach is one such approach 21 while gwas examines associations between large panels of genes and diseases nwas examines associations between all available neighborhood characteristics and disease for example two studies applied the nwas approach to study neighborhood risk factors associated with prostate cancer and poor physical activity respectively 1920 lynch et al 19 developed a multiphase approach that identified 17 new acs variables that had not been previously linked to prostate cancer mooney et al 20 used both linear regression and machine learning to identify specific characteristics of extreme poverty associated with a reduced amount of physical activity among residents in the same census tract the nwas approaches in lynch et al 19 and mooney et al 20 both consisted of two major steps the first step was a pairwise analysis to examine the associations between individual acs variables and the study outcome the second step used multivariable analysis to examine the selected variables adjusted effect on the outcome of interest we adapted an nwas approach to systematically examine associations between neighborhood characteristics and covid19 incidence among different age groups we used the illinois covid19 data and 392 acs measures to identify neighborhood characteristics associated with covid19 in eight age groups ranging from children to seniors we hypothesized that neighborhood characteristics highly associated with the incidence of covid19 vary by age groups we also hypothesized that in addition to variables widely regarded as representatives of ses we could identify other neighborhood characteristics related to agespecific covid19 incidence methods covid19 data the cumulative number of covid19 laboratoryconfirmed cases by zip code areas in illinois was published and updated daily by the illinois department of public health the compiled dataset was made available by the chicago reporter 22 we retrospectively reviewed the daily cumulative cases for 26 days may 23 through june 17 2020 the published covid19 data were reported by eight age groups due to patient privacy concerns the age groups with less than six cumulative cases were coded as zero cases by idph in the downloaded data our analysis was conducted based on zip code areas with available data for all of the eight age groups to maximize the number of zip code areas included in this study we followed a multistep approach first for each zip code area we estimated the sum of confirmed cases in all eight age groups second we calculated the difference between the total numbers of confirmed cases reported by idph and the estimated sum of all eight age groups third we selected zip code areas in which the reported total confirmed cases and the estimated sum of agespecific cases were same for the remaining zip code areas if the difference was less than six and only one age groups case number was 0 then the zip code areas with case numbers coded as zero were filled with the difference these zip code areas were also included in our analysis we focused on the same group of zip code areas with repeated estimates of daily cumulative cases for each of the 26 study days in the analysis the agespecific incidence of covid19 at individual zip code areas were calculated using the daily cumulative number of cases divided by the population at the same age population data was downloaded from the latest acs fiveyear data calculated cumulative incidences were scaled to cases1000 population in the subsequent analyses the agespecific cumulative incidence was the outcomes of interest in our analyses neighborhood characteristics neighborhood characteristics were examined using the latest acs fiveyear data we used all acs variables included in acs profiles tables which consist of more than four hundred acs variables in four categories to give a broad statistical depiction of a geographic unit ranging from nation to census block group 23 we downloaded the acs profile table in the geographic unit of zip code tabulation areas via the r 360 24 package tidycensus 25 zcta has been extensively used as a geographic unit for measuring acs estimates in epidemiologic studies because it overlaps with the postal zip code 5 the downloaded data consisted of number estimates and percentage estimates only percentage estimates were kept scaled by one standard deviation and then linked to agespecific covid19 incidences by zip code areas those scaled percentage estimates are referred to as acs variables throughout this report neighborhoodwide association study pairwise analysis pairwise analysis was conducted to measure associations between individual acs variables and agespecific covid19 cumulative incidence in a multistep process first pearson correlation analysis was used to examine bivariate relationships between any two acs variables and individual acs variables and the average agespecific covid19 cumulative incidence for the 26day study period second the association between individual acs variables and daily agespecific covid19 cumulative incidence was examined using poisson mixedeffects regression modeling poisson regression was used because disease incidence generally follow a poisson distribution 26 we included a random intercept by zip code area to account for repeated daily measurements in the 26day study period within a zip code area to adjust the varied association between social variables and population health between urban and rural areas poisson models were adjusted with a binary variable indicating whether the zip code area was identified as urban by the census bureau 17 the census bureau defined urban areas as cities with a population of more than 50000 residents and adjacent satellite citiestowns with more than 2500 residents 17 in these analyses we considered a zip code area to be an urban zip code area if fully covered by a censusdefined urban area this cutoff categorized half of our study zip code areas as urban zip codes we conducted poisson regression for every pair of acs variables and agespecific covid19 cumulative incidence a cutoff of 2tailed p 005 after bonferroni correction for multiple comparisons was used to indicate significance we illustrated pairwise analyses results using several visualization strategies that have been widely used to depict results after multiple comparisons since we were interested in identifying patterns of acs variables associated with agespecific covid19 cumulative incidence we constructed network maps of acs variables based on both correlations with other acs variables and on association with covid19 incidence in the poisson regression analyses the developed approach included two steps first we built a full network using the correlation matrix of all acs variables pairs of acs variables included in the full network had an absolute value of pearson correlation coefficient 05 and pearson correlation p 005 after bonferroni correction second we built agespecific networks with the twenty acs variables with the smallest coefficient p values in poisson regression models for two acs variables with total percent estimates always equal to 100 we only kept the one positively associated with the covid19 incidence to avoid doublecounting the same effect the twenty acs variables served as nodes in the networks and were linked through their bivariate relationship in the full network those acs variables not included in the full network were disconnected and presented in a table in the graph networks were constructed using the r packages tidygraph 27 and ggraph 28 the estimates and p values of the incidence ratios representing the change in covid19 cumulative incidences per one standard deviation increase of acs variable for agespecific covid19 cumulative incidences as well as the direction of correlation between acs variables themselves were shown using specific colors and symbol sizes in each network multivariate analysis variable selection we applied elastic net regression to select neighborhood characteristics most predictive of the agespecific covid19 cumulative incidence elastic net is a variable selection approach combining ridge regression and lasso regression both ridge and lasso regression are widely applied variable selection approaches in predictive modeling lasso regression was used in one of the two previously cited nwas studies 20 elastic nets algorithm combines the advantage of lasso regression in selecting correlated variables and the advantage of ridge regression in selecting a greater number of variables 29 which has led to elastic net becoming a top variable selection approach in environmental health research 30 in our study elastic net regression was conducted using the r package glmnet 31 during variable selection the entire study dataset was randomly divided into a 60 subset for training and a 40 subset for testing we set the proportional contribution of lasso regression versus ridge regression from 0 to 1 and then selected the model with minimal mean square error estimated from the testing subset with tenfold crossvalidation variables included in the selected model moved forward to the next step of variable selection estimate the adjusted association after elastic net regression a diagnostic test was performed using variance inflation factors to detect the remaining collinearity between selected acs variables the variable with the highest vif was excluded sequentially from the model until the vifs of all remaining variables were 25 the remaining acs variables were modeled with the agespecific covid19 cumulative incidence using poisson regression the coefficient of determination of each poisson regression model was calculated as an indicator of the variation of covid19 cumulative incidence predicted by the adjusted variables the incidence ratio and 95 confidence interval of acs variables estimated from poisson models were reported the value of the ir indicated the change in covid19 cumulative incidence per one standard deviation increase of acs variable results descriptive analysis two hundred and fourteen zip code areas in the state of illinois were included in this study the inclusion of zip code areas were based on the completeness of data in all age groups as described in the method section other illinois zip code areas were excluded in this study due to a small number of covid19 casesprivacy concerns require zip code areas with fewer than six confirmed cases to be coded as 0 cases in the downloaded dataset table 1 compares population density and urbanization for all zip code areas in illinois and for the 214 zip code areas included in the analysis the population density or percentage of the urban area was significantly higher in study zip code areas than in all the zip code areas in illinois the daily laboratoryconfirmed covid pairwise analysis figure 1 is a heat map showing the pearson correlation coefficients between 392 acs variables and covid19 incidence by eight age groups in the heat map the color gradient indicates that several acs variables were consistently correlated with covid19 incidence in age groups under 79 years old those variables represented educational attainment nonenglish speaking status employment as an essential worker health insurance status residential occupants per room and hispanic ethnicity in contrast the color gradient for the very senior age group was distinctly different from the other age groups no clear cluster of variables was observed for this age group and the colors also demonstrate relatively small correlations between neighborhood characteristics and covid19 incidence the pearson correlation coefficient tables used to create this heat map are available on this studys github site 32 figure 2 shows the example network graphs of two age groups children under 20 and seniors in 7079 years old the network graphs of other age groups are available in the supplementary material figure s29 in each network graph acs variables are shown by their ir estimated using poisson mixedeffect regression models acs variables are linked through their bivariate relationship with other acs variables estimated using pearson correlation analysis as shown in fig 2 and s29 the percent of people with european ancestries was negatively associated with covid19 incidence across all age groups besides that networks differed between age groups in the network for children under 20 we observed five clusters of acs variables health insurance raceethnicity neighborhood characteristics associated with covid19 burdenthe modifying effect of age and educational attainment connecting the former two clusters and a detached cluster dominated by employment as an essential worker among them clusters of health insurance raceethnicity and education attainment were found in the networks of age groups under 20 to 59 for two senior age groups acs variables related to marital status were on the networks the details of acs variables significantly associated with agespecific covid19 incidence are available in supplementary material table s1 the us census bureau categorizes all acs variables into 43 subjects we identified subjects of acs variables that were generally associated or not associated with agespecific covid19 incidence by the proportion of significantly associated acs variables within the subject results were available in supplementary material table s1 variables representing computer access fertility and residential occupants per room were highly associated with covid19 incidence for age groups under 79 overall covid19 in adults between 40 and 59 was associated with a greater number of acs variables than other age groups only one acs variable was significantly associated with covid19 incidence in the very senior group multivariate analysis table 2 shows the acs variables identified as significant predictors of agespecific covid19 cumulative incidence in each step of variable selection in the first step elastic net selected zero to 41 acs variables that were highly predictive of agespecific covid19 cumulative incidence the number of selected acs variables differed by age group among the eight age groups the 3040yearold age group had the most acs variables selected by elastic net regression followed by the pediatric age group only one acs variable was selected as a predictor of covid19 the name of each acs variable indicates the percent of people comparing to the reference population in a zip code area for example the 2 units per building means the percent of people living in a building with two units among all people whose housing information was available cumulative incidence in the 7079 age group no acs variable was identified as a significant predictor in the oldest group in the second step of multivariate analysis after removing the acs variables with higher vif for example from the youngest to the 4050yearold age group the percentage of people who carpool to get to work was the most important predictor of covid19 cumulative incidence older housing and crowded housing were also significant predictors of covid19 cumulative incidence in adult groups several protective factors were also identified acs variables related to europeanancestry were associated with a lower incidence of covid19 ranging from the youngest age group to the 6070yearold age group in addition multiple acs variables related to low housing cost compared to income were associated with lower covid19 cumulative incidence in the 3040yearold age group we compared the results of pairwise analysis and multivariate analysis of the acs variables and their associations with agespecific covid19 cumulative incidence we identified several factors in common between the results of fig 3 network of two age groups each graph consisted of the twenty american community survey variables most significantly associated with the agespecific covid19 incidence the associations between each acs variable and the agespecific covid19 cumulative incidence were presented as specific color and size of node network was built based on the correlation between acs variable the network graphs of two age groups 20 and 7079 were shown here the networks for all age groups were available in the supplementary material pairwise analysis and multivariate analysis results hispanic ethnicity was significantly associated with incidence of covid19 disease populationlevel marital status was significantly associated with covid19 incidence in older ages but not in younger ages acs variables directly related to neighborhood socioeconomic status had a stronger association with covid19 incidence in children than in older adults several inconsistencies were also observed variables related to health insurance status and educational attainment were strongly associated with covid19 incidence in the pairwise analysis and in the preliminary variable selection by elastic net regression but were excluded by vifbased selection in the multivariate analysis the pairwise analysis and multivariable analysis identified different significant acs factors related to incomehousing cost as a percentage of income was highly associated with covid19 incidence in multivariable analysis while the family income variables which also represent the family financial situation were associated with covid19 cumulative incidence in pairwise analysis discussion using a nwas method and zip codelevel covid19 and neighborhood characteristics data we found that the incidence of covid19 disease early in the pandemic was unequally distributed among neighborhoods based on differing social economic demographic and housing factors this finding contributes to the evidence that sesdisadvantaged neighborhoods are associated with increased risk of a number of health problems including covid19 1114 second age modified the associations between neighborhood characteristics and the covid19 incidence to our knowledge this is the first study to examine the crosssectional association between neighborhood characteristics and covid19 incidence by age groups the age composition of the covid19 cases found in our study zip code areas was similar to that reported in china 2 and elsewhere in the us 33 early in the pandemic among all covid19 cases the proportion of people under 20 years old ranged from 1 to 10 which was disproportionally lower compared to the proportion of people in this age range in the general population 734 in addition to the biological mechanisms highlighted in previous studies our findings suggested that neighborhood environment might also contribute to differing covid19 incidences between children and other ages in our study covid19associated neighborhood characteristics were more diverse and more significant in middleaged adults than in children and young adults this might be explained by greater exposure to certain neighborhood factors among middleaged adults compared to younger people after social lockdown measures were enacted childrens daily activities are usually restricted to their local community and school district and became even more restricted after schools and community activities closed middleaged adults daily activities were more diverse before pandemic closures than those of children including commuting working grocery shopping etc and many of these persisted by necessity despite broad lockdown orders our study further confirmed that disadvantaged neighborhoods and older age jointly contribute to the elevated incidences of covid19 disease in our study zip code areas characterized by lower educational attainment and hispanic ethnicity had a disproportionately higher incidence of covid19 these influences were more significant for children and middleaged adults compared to older adults fewer acsmeasured neighborhood characteristics were associated with covid19 in adults older than 70 suggesting that older age remains the most important risk factor for covid19 333536 although fewer acs variables were associated with covid19 in seniors than in younger ages more than onethird of study neighborhood characteristics were still statistically significantly associated with covid19 incidence in people aged 6079 years in the pairwise analysis in multivariate analysis neighborhood characteristics selected from an objective multistep approach contributed 66 and 24 of the variation in covid19 incidences in the 6070 and 7980 age groups respectively considering the mortality risk of senior covid19 patients the impact of this groups neighborhood environment cannot be ignored our study identified several neighborhood characteristics that have not been linked with covid19 in previous studies for example in both pairwise analysis and multivariable analysis residents marital status was a significant neighborhood characteristic associated with the covid19 incidence early in the pandemic among people older than 50 covid19 incidence was positively associated with the percent of unmarried people and percent of people living alone at zip code levels likewise covid19 incidence was inversely associated with the percentage of people living with a spouse notably as depicted in the network graphs zip codes with a higher percentage of married people also had a greater white population which has been widely used as an indicator of neighborhood ses 37 and has been previously noted as a protective factor of covid19 1314 we originally thought that the effect of zipcodelevel marriage rate might be instead due to the effect of ses however no marital variables were found in the networks of highly associated neighborhood characteristics of age groups younger than 50 years old in the pairwise analysis also the multivariate analysis suggested a significant association between zipcodelevel marriage rates and covid19 incidence in the 5060yearold age group after adjusting for other selected ses variables these results suggest that the effect of marriage on covid19 incidence was distinct from ses among older adults this is particularly interesting considering the infection risk conferred by the reduced possibility of social distancing among married couples cohabitating compared to unmarried individuals a possible explanation is that locations with higher rates of older adults living with their spouses would likely have fewer people living in nursing homes where residents are at high risk of highly infectious diseases like covid19 in illinois about half of counties reported covid19 outbreaks in longterm care facilities 38 living with a spouse might be a marker of not living in a longterm care facility which may be why the zip code areas with more married seniors have lower covid19 incidence future analysis could include the determination of housing type which was not possible in the present study transportation was found to be an influential factor of covid19 incidence in our study in the pairwise analysis the only neighborhood characteristic found to be significantly associated with covid19 incidence in people older than 80 was the percent of people who take public transportation to work in a zip code area in multivariate analysis the percent of people who take carpool to work was widely associated with increased covid19 incidences in age groups ranging from children to middle age public fig 4 results of multivariate analysis incidence ratio and 95 ci between american community survey variables and agespecific covid19 cumulative incidence estimated by multivariate poisson regression acs variables adjusted in each poisson model were selected using elastic net regression and variance inflation factor unit of incidence ratio change in the agespecific covid19 cumulative incidence per one standard deviation of acs variable the name of each acs variable indicates the percent of people compared to the reference population in the study area for example the 2 units per building means the percent of people living in a building with two units among all people whose housing information was available in the study area transportation could be a hub of transmission for the sarscov2 virus reduced immune response and existing chronic diseases could elevate the risk of covid19 infection and severe syndromes in older adults 3536 in general carpools are considered less risky than public transportation given people are contacting less frequently in carpools than in public transportations but the increased risk of covid19 among zip codes with more people takes carpools indicated that the reduction of contact at this extent could not efficiently prevent covid19 our study has several limitations first our ecological study design cannot make causal inferences between neighborhood characteristics and covid19 disease second although zctas have been widely used in public health studies to estimate sociodemographic status at matched postal zip code levels 24 this study is subject to possible minor misclassification because the neighborhood characteristics in our study were measured by acs at the geographic unit zcta while covid19 cases were reported by postal zip codes another limitation which universally exists in studies using the pairwise analysis and nwas framework is that the study is an agnostic hypothesisgenerating rather than hypothesistesting approach this limitation is inherent in our exploratory study design which was to identify new neighborhood characteristics whose associations with agespecific covid19 incidence could have been missed by methodologies despite these limitations our study applied a novel method to examine the association between covid19 infection rates and neighborhood characteristics and age we systematically examined associations between 392 acs variables and agespecific covid19 incidence the visualization tools we used proved to be powerful ways of exhibiting the association between neighborhood characteristics and covid19 incidence across age groups the variable selection and multivariate regression analysis estimated associations between neighborhood characteristics and agespecific covid19 incidence adjusting for other neighborhood characteristics as possible confounders the identified neighborhood characteristics associated with agespecific covid19 incidence highlight opportunities for further study of highrisk populations by their age and living environment conclusion in the present study we systematically reviewed the association between 392 acsmeasured neighborhood characteristics and agespecific covid19 incidence in 214 illinois zip code areas covid19 cases were disproportionally distributed in neighborhoods characterized by lower educational attainment crowded households and higher numbers of essential workers lower neighborhood ses was a significant risk factor for covid19 across age groups particularly among children however neighborhood social characteristics such as marital status and housing conditions were additional risk factors for covid19 among seniors further study to better understand the epidemiology of covid19 should consider both the neighborhood environment and the populations age code availability the entire analytic procedure is depicted in fig 1 r code and detailed analysis results are available on github 32 compliance with ethical standards conflict of interest all authors declare no competing interests publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

background neighborhood characteristics have been linked to community incidence of covid19 but the modifying effect of age has not been examined objective we adapted a neighborhoodwide analysis study nwas design to systematically examine associations between neighborhood characteristics and covid19 incidence among different age groups methods the number of daily cumulative cases of covid19 by zip code area in illinois has been made publicly available by the illinois department of public health the number of covid19 cases was reported for eight age groups under 20 2029 3039 4049 5059 6069 7079 and 80 we reviewed this data published from may 23 through june 17 2020 with complete data for all eight age groups and linked the data to neighborhood characteristics measured by the american community survey acs geographic agespecific cumulative incidence cases per 1000 people of covid19 was calculated by dividing the number of daily cumulative cases by the population of the same age group at each zip code area the association between individual characteristics and covid19 incidence was examined using poisson regression models results at the zip code level neighborhood socioeconomic status was a more important risk factor of covid19 incidence in children and workingage adults than in seniors social demographics and housing conditions were important risk factors of covid19 incidence in older age groups we additionally observed significant associations between transportationrelated variables and covid19 incidences in multiple age groups significance we concluded that age modified the association between neighborhood characteristics and covid19 incidence• environmental justice • geospatial analyses xueying zhang

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introduction this viewpoint is centred on vaping also known as electronic cigarettes and positioning its explosive growth as a form of irresponsible leisure within tourism vaping is broadly defined as a device that generates vapour for individuals to inhale without firelighting requirements vapes also come in disposable and refillable types and come in an assortment of flavours figure 1 shows examples of vaping devices with the global popularity of vaping on the rise southeast asian countries become attractive destinations for vaping enthusiasts looking for unique experiences the regions diverse cultures and geographical beauty provide a setting for tourists who may want to indulge in their vaping pursuits as they travel however the rapid expansion of this trend presents issues for local governments notably in monitoring the impact on public health safety and the environment according to baker there were 82 million vapers globally with the sector having a net worth of us 228 billion in 2022 vaping is popular among teens and young adults because it is cheaper than traditional nicotine tobacco products and caters to individuals based on their preferred tastes ironically vaping was introduced as an alternative to assist with smoking cessation but has instead become an epidemic because more young people have been diagnosed with some form of addiction in the philippines a call to action for youths use has been dedicated to further assist in this dilemma further academic and market research has also found that vaping can result in greater nicotine consumption than traditional cigarettes and lead to a range of health diseases and conditions yet the number of vapers continues an upward trajectory the prominence of vaping in southeast asia has not gone unnoticed liu estimated that the vaping market in southeast asia is worth us 766 million nevertheless different regulations can be observed across the different southeast asian countries naval reported that five countries have banned vaping brunei cambodia laos singapore and thailand others like the philippines frame vaping as a less harmful alternative to cigarettes in contrast indonesia has raised excise tariff taxes on vaping to 10 to curb the growing market however in vietnam products such as vaping are currently not allowed to be imported sold or circulated in the domestic market however the buying selling and advertising of these products are widespread especially on the internet in a technologically ubiquitous environment vaping is marketed through digital influencers thereby exposing younger audiences to witness it as a socially acceptable practice among ones peer group or network in the philippines the rate of vaping has increased because of the ease of accessing vapes and as a leisure practice that can be enjoyed individually there is a perception of generating less harm to society however the policing by residents in thailand on vaping behaviour has resulted in greater enforcement and clampdowns in public according to ngan the rate of vaping usage in vietnam in 2020 among both men and women has increased 18 times compared to 2015 with a high concentration in the age group of 1524 with a rate of 73 compared to other age groups different countries portray their stance on this highly polarising practice but from a responsible tourism perspective should vaping be permitted current studies on vaping are highly skewed from a public health perspective with little effort to understand the sociocultural motivations for such leisure practices whether inperson or online in acknowledging that there are health risks involved in vaping little has been done in terms of examining whether the practice is considered a less deviant form of leisure for instance does vaping result also in passive smoking effects also is vaping a more sustainable form of leisure more critically will southeast asian nations accept the possible development of vapinginduced tourism in other words tourists travelling across borders to engage and participate in such practices as a primary or secondary motivation the policies to date do not reflect some of these nuances associated with vaping meanwhile from historical interpretations vaping is smoking which is interpreted as an activity that harms society there are some challenges and concerns related to vaping and tourism activities health and safety implications vaping is becoming increasingly and more popular among travellers raising questions about possible health effects and safety hazards southeast asian nations renowned for their varied regulatory frameworks confront the difficulty of reconciling the needs of tourists with the protection of public health and safety environmental impact irresponsible disposal of vaping devices and eliquid containers can pollute the environment southeast asian countries already coping with environmental concerns must address the responsible disposal of vapingrelated waste to minimise its impact on local ecosystems and cultural sensitivity vaping may violate cultural norms in some southeast asian countries where smoking and hence vaping is discouraged balancing the desires of tourists with cultural sensitivity is a delicate task for destination authorities narcoticinduced tourism the use of narcotics as an attractive proposition for tourism has piqued academic and industry interest over the last few decades related to southeast asia thailands recent decriminalisation of marijuanacannabis has resulted in a mushrooming of shops offering a range of productsservices to locals and tourists even though the recreational consumption of marijuana in public is illegal there is nothing to prevent tourists from using these in their private accommodations amidst this backdrop some local communities are already petitioning the thai government to put marijuana back again on the list of narcotics in fear that young people may be exposed and fall into a downward spiral of addiction the ministry of health vietnam believes that vaping is harmful to health and is currently being mixed with drugs leading to addiction vietnam has taken steps to completely ban all forms of buying selling manufacturing and importing these new products the above discussion is of direct relevance to vaping because it has also become extremely popular with young people and can be easily accessed publicly however from a responsible tourism vantage point there needs to be further conversation and analysis about this controversial topic arguments for and against vapinginduced tourism proponents of vapinginduced tourism would be stimulated by the economic recovery of such a growing segment in a postpandemic landscape the novelty and acceptance of vaping in some southeast asian countries can be a pull factor for inbound tourism markets especially in the aftermath of the covid19 pandemic likewise the acceptability of vaping in or within proximity of coffee shops or restaurants can also be an opportunity to increase sales of tourism and hospitality products and services which in turn also enhances the multiplier effect through job creation and other forms of secondary expenditure vapinginduced tourism can also be a form of responsible leisure when tourists are educated as to where and what products are safer for consumption as compared to cigarettes the knowledge creation process reduces the unintended risks and dangerous practices associated with unregulated vaping of unsafe substances which may go unnoticed in countries where vaping education is absent or minimal opponents of vapinginduced tourism point to the potential for tourists to participate in reckless acts that may lead to health risks and place pressures on health facilities indestination when medical attention is warranted in addition tourists may influence local community behaviour especially among young people to deem vaping as socially acceptable worse still local communities may become addicted to vaping as compared to when such substances are deemed contraband and not circulated in the country in the philippines vaping is not permitted in public areas and visitors are advised not to enter the nation with these items however it is still a problem within the established tourist destinations the banning of vapes in half of the southeast asian countries has reduced the propensity for tourists to bring in such devices when travelling in the region the existence of such regulations assists in providing locals and other tourists with a pleasant experience and creates a positive destination image which can result in repeat visit intentions there is also very little reporting on the environmental hazards posed by the pollution effects and irresponsible disposal of vapes at a destination vapes contain high elements of plastic and metals and the products are stubbornly difficult to break down for recycling this adds no value to the ethos of sustainable and responsible tourism practices especially when vapes exacerbate waste problems at a destination regulating the vaping landscape regarding the vaping landscape in southeast asian countries it would be extremely good if there were rules to ensure that the ideals of responsible leisure are constantly upheld a c designated vaping zones some southeast asian countries could consider creating designated areas for vaping within tourist destinations this allows tourists to enjoy their vaping activities without compromising the experience of nonvaping tourists or violating local regulations conclusion in conclusion responsible tourism in the context of vaping must also consider the underlying responsible leisure practices associated with this growing trend it is an evolving market with many governments largely catching up in terms of public health advisory and regulations nevertheless there are initial steps taken to ensure vapes are not misused nor abused under the pretext of tourism ongoing and proactive strategies arguably at a regional level eg association of southeast asian nations may be required to level the playing field for responsible tourism and vaping practices to flourish as southeast asian countries continue to attract a variety of tourists controlling the vaping landscape becomes an urgent priority maintaining a balance between encouraging tourism preserving public health and safety and honouring cultural sensitivity is essential through effective regulation enforcement and public awareness initiatives southeast asian countries can navigate the challenges posed by the intersection of tourism and vaping creating an environment where both tourists and locals can coexist harmoniously

vaping also known as electronic cigarettes has taken the world by storm and is now a multimilliondollar global industry yet government policies and regulations do not keep pace with the segments explosive growth some countries have banned the sale of such products outright though others have enforced rules surrounding its circulation nevertheless vaping products appear easily accessible through online sales channels and often fall into the hands of a younger market segment vaping is considered a national issue among many countries due to rising rates of youth adoption and addiction the rise of vaping can be explained by its framing as a more desirable alternative to traditional tobacco products as well as its range of flavours to suit different peer and subculture groups nonetheless this viewpoint traces the development of vaping in several southeast asian countries and the development of several government policies and regulations related to responsible tourism this viewpoint explores the scenarios of vapinginduced tourism and support for or against such a development framed through the lens of a narcoticsinduced tourism lens this viewpoint argues how vaping can be classified as a form of irresponsible leisure in tourism drawing upon its social and environmental negative outcomes future strategies and actions are proposed to help countries stem the tide of vaping especially from an inbound tourism perspective

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introduction moral orientations are defined as organized principles linked to existential judgments influencing human behavior allowing one to make decisions of moral nature moral orientations or types of morality are often described as axes or standards validating accepted norms related to them the fundamentals of moral orientations lay in the phenomenon of how people validate norms values convictions verbalized judgments and evaluations they themselves find appropriate the essence of a moral orientation is driven from seeking an answer to the question why a specific • dr dominik szczygielski john paul ii catholic university of lublin institute of sociological sciences publication address ul radziszewskiego 7 20039 lublin poland email orcid behavior ought to be condemned in pluralist societies it is natural to expect the occurrence of a variety of moral orientations one of the most important differentiations of moral orientations is the typology proposed by janusz mariański in this approach moral attitudes range from prosociality to egoism on a threestep continuum attitudes towards people attitudes away from people and attitudes against people according to mariańskis approach moral attitude towards people is oriented towards sacrificing oneself for the benefit of others avoiding conflicts and rivalry broadening the circle of people one endows with generalized trust this approach heavily marked with allocentric values and selflessness results in the moral development to the point where individuals creatively synthetize private goals with those of others for the benefit of personal satisfaction attitude away from people stems from the need of independence and autonomy this moral orientation is characterized by the need of distancing oneself from others and not seeking emotional engagement those who represent this moral attitude focus on trusting themselves or the close circle of trusted people this approach is free from hostile reference but is also characterized by a lesser sensitivity towards values of selflessness to complete the spectrum of moral attitudes the attitude against people is worth mentioning individuals representing this moral approach perceive social environment as hostile and competitive the vision of human nature is marked by egoist drives and selfinterest this attitude involves unfriendliness hatred isolation manipulating others for ones own profit lack of empathy neglecting the point of view of partners of social interaction indifference to the needs of outgroups the imperative of rivalry and competition prevents individuals representing this moral orientation from prosocial participation and active engagement for the common good other traits related with the attitude of negative competition emphasize the need to elevate oneself at others expense neglecting social cooperation treating others as means to achieve private goals in sociological literature one may find various explanations of prosocial attitudes the most commonly known is the one emphasizing the role of social norms peoples concern for the good of others is the result of adopting social norms encouraging them to behave in a way that is beneficial to society and is socially rewarded by acts of approval or prohibition when norms are violated another explanation assumes that prosociality is motivated by the need for gaining respect and good reputation people undertaking prosocial activity are viewed as more respectable trustworthy attractive in terms of social interactions and finally being embedded in social relations might be a sufficient explanation for prosociality itself dense social networks and relations entail exposure to the needs of others resulting in moral obligation or commitment to the public good various studies show that networks and relations promote generalized trust to strangers as a result of broadening the potential social perspective through positive experience with others or enhance solidarity by paying off social debts in interactions with random individuals yet another observation is worth mentioning as research shows collectivist cultures may inhibit generalized trust due to dense social relations that may work as potential ostracizing mechanism in case of exploitation thus preventing confidence in others good intentions to develop in the long run various sociodemographic and individual factors described in literature influence the general attitude towards prosociality for example age has a significant impact on prosociality as an individual grows older the level of prosocial activity increases city size turns out to be a significant factor of prosociality towns dwellers are more willing to engage in helping behavior than residents of cities religious factors also need to be taken into account according to shariff and norenzayan mentioning religious concepts like god divine spirit and prophet in experiments increases the tendency to allocate money to anonymous strangers van lange and colleagues reported the existence of a positive link between gender and helping behavior according to their studies women declared prosocial value orientation more often than men and individualistic value orientation less often than men another factor worth taking into consideration is social capital the key elements of social capital are found in putnams work who defined it as connections among individuals social networks and the norms of reciprocity and trustworthiness that arise from them in social sciences level of education is considered to be one of the most important variables positively shaping the prosocial behavior the concept of social capital helps to understand why education plays such a significant role people with a higher level of education are exposed to various social situations through which they build their networks skills and abilities that eventually allow them to act prosocially on the basis of greater sense of responsibility awareness and empathy trust seems to be a particularly interesting predictor of prosocial moral attitude as it is observed higher trust leads to more prosocially oriented behavior as it is central to the development of a sense of interdependence with others and contributes to the belief that others will reciprocate an amount of research proves the existence of the link between prosocial behavior and generalized trust as well as institutional trust the findings of the latter introduce a new perspective to the analysis according to andrianis and sabatinis study institutional trust can be a better predictor of prosociality than other forms of trust in the light of this discovery another important question can be asked is social trust as well as institutional trust a better predictor of prosocial attitudes towards people than other essential variables like for instance religion or education it seems there is still the need for further sociological studies that would focus predominantly on a variation of social trust called institutional trust using diverse statistical procedures the purpose of this article is to fill this gap and to shed more light on the matter the main objectives for this article are to answer the following questions 1 to what extent given moral orientations are prevalent within polish society 2 what is the correlation between moral orientations types of social trust and various sociodemographic determinants 3 which sociodemographic and cultural determinants have been found to increase or decrease the examined moral orientations taking into account the above presented theoretical frames three hypotheses will be tested h1 greater susceptibility to moral orientation towards people is to be detected among respondents representing higher level of social trust a higher level of religiosity a higher level of education residence in larger cities h2 greater susceptibility to moral orientation against people is to be detected among respondents representing a lower level of social trust a lower level of religiosity a lower level of education residence in smaller cities h3 in traditional polish society the odds ratio of prosociality is higher for religiosity than other alternative variables materials and methods to answer the abovementioned research questions data from the european values study have been used european values study is a multinational longitudinal research project focusing on measuring human values and social attitudes to focus on the recent and up to date findings within the polish society the fifth wave of evs 2017 has been included into the analysis the basic concept of moral attitudes towards people and away from people have been measured using the following variables in the dataset with response ranging between 1 very much 2 much 3 to a certain extent 4 not so much 5 not at all v212 are you concerned with peoples neighborhood v213 are you concerned with peoples own religion v214 are you concerned with fellow countrymen v215 are you concerned with europeans v216 are you concerned with humankind v217 are you concerned with elderly people v218 are you concerned with unemployed people v219 are you concerned with immigrants v220 are you concerned with the sick and disabled the initial characteristics of the scale built upon the abovementioned items is as follows the factor analysis reveals two dimensions the first is based on variables v212v216 emphasizing concern regarding broader circles of people and second one based on variables v217v220 accentuating social empathy towards disadvantaged groups for the purpose of meeting the theoretical criteria of mariańskis concept a complete set of nine variables was used to build the social empathy index the reliability of such index achieved a very satisfying degree of reliability the indicators describing characteristics of distribution have reached results allowing to assume its normality twentyfour cases of extreme values were removed from the set slightly improving its characteristics results prevalence of moral attitudes in poland in the process of twostep cluster analysis the social empathy index allowed us to automatically produce three clusters corresponding to the theoretical framework the distance measure used for clustering was the loglikelihood criterion the analysis provided the following results the dominant moral orientation regarding maintaining social bonds is keeping away from people the second most common orientation is against people almost a third of poles are characterized by lack of concern for others attitude towards people is represented by almost a quarter of poles the following groups differ by means reached on the social empathy index the lower the mean the greater the social concern about broader categories of people external to individuals clustered in segments factors of moral attitudes in poland size of town and educational level various sociological determinants differentiate presented moral orientations procedures of statistical analysis reveal the existence of statistically significant correlation between size of town where interview was conducted and attitude towards people according to analysis representatives of an attitude towards people are more likely to live in medium size cities or metropolitan areas findings presented in table 2 lead to the conclusion that along with the increasing size of town the likelihood of attitude towards people also rises further examination showed no statistically significant correlations between the size of the town where an interview was conducted and the attitude away from people as well as the attitude against people additional investigation revealed statistically significant correlation between educational level and type of moral orientation in order to allow χ 2 calculations the initial variable describing educational level has been transformed by removing the least numerous extreme categories no formal or less than primary education and other data shown in table 3 afford an interesting observation regarding educational level and attitude towards people the probability of occurrence of attitude towards people is higher among respondents who obtained advanced degrees of education in comparison to lesser educated individuals among respondents oriented towards people the proportion holding an ma is almost twice as large as those who concluded their education at the primary level on the other hand as the level of education increases the percentage of respondents representing less prosocial orientations decreases in consequence the conclusion additionally backed by statistical calculations is that a higher degree of education supports the attitude of social proximity and engagement inverted regularity is evident in the case of segment accumulating attitudes against people as it is shown in table 4 the proportion of individuals representing this moral orientation decreases as the level of education increases reaching almost double decline between participants who received only primary education and those with masters diploma parallelly respondents who received university education present higher susceptibility for other moral orientations than that of attitude against people the above observations find its confirmation in statistical tests no significant correlations were found in the case of attitudes away from people religion according to the conducted analysis religious determinants are statistically significant correlates of moral orientations the tstudent test for two independent samples revealed interesting observations among segments of moral orientations when respondents were asked about the importance of god in their life using a 10point scale ranging from 1 not at all important to 10 very important proponents of healthy and trustful social interactions with a broader circle of individuals declare higher importance of god in their life in comparison to adherents of other moral orientations the observed difference meets assumed criteria for statistical significance 2500 p ≤ 005 and leads to the conclusion that a higher level of religiousness promotes attitudes towards people the opposite regularity is observed in the segment of respondents driven by selfinterest in social relations as the results of the t test demonstrate the importance of god among those representing the attitude against people is significantly lower in comparison to other moral segments the mean value on the scale of importance of god in life for the segment against people reached 752 while for other segments combined the same indicator was 785 the results of the t test validate the conclusion that lower level of religiousness favor occurrence of attitudes against people 1971 p ≤ 005 regarding individuals clustered in the segment of attitude away from people no significant differences were found interpersonal trust aside from prosociality societies in order to maintain a stable system need a specific type of bond based on an expectation that other members will act and behave in helpful and reliable manner that is beneficial to partners of social interaction this type of bond is described as social trust and is usually categorized in two forms interpersonal trust when it refers to ingroup members or institutional trust generally described as confidence of citizens in institutions in the analysis two types of trust can be measured using the available set of variables to generate interpersonal trust index the following variables have been used v33 how much you trust people in your neighborhood v34 people you know personally v35 people you meet for the first time v36 people of another religion v37 people of another nationality to each question was added a scale of responses ranging from 1 do not trust at all 2 do not trust very much 3 trust somewhat 4 trust completely was added the response scale was transformed from its original descending form to ascending order an interpersonal index scale so constructed exhibits satisfying level of reliability this level of cronbachs alpha has been reached by excluding the first position available in the set how much you trust your family the initial interpersonal trust index ranging from 5 to 20 points for the purpose of χ 2 analysis has been recoded to the form of a 5point scale table 5 presents the distribution of interpersonal trust and moral orientation towards people the conducted analysis shows that only every twelfth member of this segment reports complete lack of trust in interpersonal relationships while more than a third of respondents in this category declare belief in helpfulness and trust towards partners of interaction the observed relation is twofold an increasing level of interpersonal trust progressively raises the percentage of those affiliated with attitude towards people and a decreasing level of interpersonal trust raises the fraction of representatives of other moral orientations where 9 out of 10 respondents declaring complete lack of trust in social interaction will belong to a segment other than towards people the above observed relation is statistically significant interpersonal trust is one of the factors shaping affiliation regarding attitude against people this moral segment is heavily marked by a complete lack of trust half of its members are characterized by no confidence in others good will along with the increasing level of interpersonal trust the fraction of members of this moral segment also diminishes most visibly at the level 4 of interpersonal trust where only a fifth is accounted as members of this moral segment those declaring complete trust constitute one third of this segment in conclusion a lower level of interpersonal trust significantly contributes to the attitude against people and a higher level of interpersonal trust decreases chances for representing this moral orientation the observed differences have been confirmed as statistically significant using the χ 2 test moral orientation away from people proved no significant correlation with interpersonal trust institutional trust confidence of polish citizens in institutions has been measured using 14 items available in the evs 2017 dataset v115 how much confidence in church and the following v116 armed forces v117 education system v118 the press v120 the police v121 parliament v122 civil service v123 social security system v124 european union v126 health care system v127 justice system v129 environmental organizations v130 political parties and v131 government items regarding trade unions united nations organization major companies and social media have not been included due to the large proportion of do not know answers coded as missing values the reliability of such index achieved satisfying level of reliability respondents answered using 4point scale where 1 a great deal 2 quite a lot 3 not very much 4 none at all in the process of transformation original points have been inverted so the index could form an ascending order initially the institutional trust index ranging on a scale between 14 and 56 has been adjusted by removing extreme values which resulted in following coefficients of normal distribution skewness 0057 and kurtosis 0058 n 996 missing values 356 ultimately the index ranging between 16 and 48 has been further on recoded to form a 5point scale confidence of citizens in institutions results in higher predisposition to represent attitude towards people in the segment of moral orientation towards people the percentage of respondents reporting full institutional trust is almost three times higher than individuals acknowledging complete disbelief in institutions the fraction of representatives of this moral orientation increases throughout the ascending span of institutional trust on the other hand probability for representing alternative moral orientation decreases with every other rising level of institutional trust while almost 9 out of 10 members of alternative moral orientation declare complete distrust towards institutions only 6 out of 10 would represent a similar moral view if they shared contradictory opinions on institutions applied statistical procedures confirm that reporting greater confidence in institutions results in increased chance for representing allocentric concerns the correlation between attitude away from people and institutional trust is the first confirmed association regarding this segment the conducted analysis shows that increasing confidence in institutions favors other moral orientations than the attitude centered on social restraint this conclusion is drawn from the fact that on the scale of institutional trust the fraction of those representing other moral orientation between extreme levels rises by 74 pp invert regularity characterizes the investigated segment along increasing trust in institutions the chances of representing this moral segment drop the difference in proportion between skeptics and proponents of institutional activity in poland differs by the same value of 74 pp the statistical difference has been confirmed by the appropriate test the significance of institutions in the process of strengthening social bonds is visible in the case of attitude against people strong belief in institutions clearly limits the spread of moral apathy regarding this social environment findings presented in table 9 justify the statement that as trust in institutions improves the proportion of membership in the segment against people diminishes while almost half of respondents declaring a complete lack of trust in institutions are accounted for this moral segment the proportion of individuals positively assessing activity of institutions and not being concerned for others constitutes only a quarter invert regularity is observed in the parallel segment while sceptics make up more than a half of all respondents representing other moral orientations satisfied with activity of institutions constitute almost three fourths of this grouping this leads to the conclusion that stronger confidence in institutions inhibits the attitude centered on selfinterest and lack of concern for others additionally this interpretation is sustained by conducted statistical calculations interpersonal and institutional trust importance of god size of town and educational level as predictors of moral orientations the final stage of statistical analysis included binary logistic regression its purpose was to examine the efficacy of earlier tested variables and to build models that could explain the occurrence of analyzed moral orientations additional analysis using the spearman measure revealed the existence of negligible or weak correlations between social empathy index and interpersonal trust as well as institutional trust in their 5intervals forms there was a negative weak correlation between social empathy and interpersonal trust 266 p 001 the association between social empathy and institutional trust has been proved to be very weak 167 p 001 other tested variables also proved negative correlations with social empathy index of 167 and lower with a corresponding p value of 05 logistic binary regression allowed us to estimate the likelihood of two types of attitudes towards people and against people no significant observations were found for the attitude away from people selected variables have been entered into the model in a sequential mode keeping its recoded form as previously tested using χ 2 statistics in the case of attitude towards people the following variables have been included in the analysis interpersonal and institutional trust importance of god size of town the first tested variable was interpersonal trust coded on a 5point scale entering this variable results in the conclusion that interpersonal trust increases odds of attitude towards people although this model explains only 57 of variance there are no prerequisites to question its significance and goodness of fit b coefficient for interpersonal trust tested as positive number which means that this predictor increases the likelihood of the moral orientation centered on prosociality further analysis shows that by raising interpersonal trust by 1 point chances for attitude towards people to occur rise by almost 80 1798 step 1 r 2 0057 χ 2 39349 p 0001 hl 0091 step 2 r 2 0082 χ 2 46658 p 0001 hl 0317 step 3 r 2 0090 χ 2 50801 p 0001 hl 0842 step 4 r 2 0097 χ 2 54889 p 0001 hl 0981 in the next step institutional trust coded on a 5point scale has been added to the model appropriate coefficients leave no doubts regarding significance and goodness of fit entering subsequent predictor rises measure of variance for the dependent variable to 82 both b coefficients of tested variables are marked positively which allows one to expect its progressive effect on the dependent variable the odds ratio for the tested independent variables 1782 and exp 1455 respectively indicate that a unit increase in interpersonal trust and institutional trust raise the chances for attitude towards people by 78 and 45 respectively in the third step importance of god in life coded on a 10point scale was added to the model a subsequent addition of independent variable makes it possible to build a model explaining 9 of variance of the dependent variable required coefficients for significance and goodness of fit allow further analysis all b coefficients for three predictors are marked positive which means that these variables improve the likelihood of event including importance of god in the model slightly weakens the effect of institutional trust rising its value by one unit will result in an increased odds ratio of the occurrence of the tested attitude by 38 1383 79 in case of interpersonal trust 1796 every 1point increase in importance of god in life will increase odds ratio for the event to occur by 8 1080 finally the size of town has been added as a fourth and last independent variable an initial analysis leads to the conclusion that model fits well to the data each dependent variable increases the likelihood of the tested moral orientation since logistic regression coefficients for all predictors are positive numbers adding the size of town variable slightly weakens the effect of interpersonal trust and strengthens the effect of institutional trust now a unit increase of interpersonal trust will result in 75 increase of odds ratio in the occurring of attitude towards people 1753 a similar change within institutional trust will now result in 41 increase of odds ratio 1417 almost a 10 increase of the odds ratio in favor of the tested moral orientation would be a result of a 1point increase of importance of god 1097 a unit increase in size of town would result in the increase of odds ratio by 13 1135 model based on four predictors would explain almost 10 of variance first three variables interpersonal and institutional trust as well as importance of god are significant negative predictors of the opposite moral orientationattitude against people the model explaining the occurrence of this type of attitude can be supplemented by educational level all of the tested independent variables work as inhibitors of attitude against people in the first step adding interpersonal trust results in a model of disputable coefficients although the model is significant the hosmerlemeshow statistics suggest further exploration for additional variables the negative value of logistic regression coefficient for interpersonal trust indicate its inverted causation in case of attitude against people a unit increase of interpersonal trust results in reducing odds ratio for this moral orientation by 40 0603 the model based on interpersonal trust explains only 55 of the variance of the dependent variable institutional trust seems to be having a similar effect on attitude against people it reduces the likelihood of the tested moral segment initial statistics suggest further search for set of variables that would complement the model but basic coefficients allow preliminary estimations logistic regression coefficients for both predictors are negative numbers which indicates a negative relationship between variables increasing both predictors by 1 point will decrease the likelihood of the tested moral orientation by 39 in the case of interpersonal trust 0614 and 29 in case of institutional trust 0713 adding institutional trust would improve variance of the dependent variable to 77 if importance of god is added in subsequent step of the analysis coefficients of significance and goodness of fit reach satisfying values model built on three independent variables fits data well and explains 83 of variance of the dependent variable all of the predictors have a negative effect on the likelihood of the attitude against people this conclusion is drawn from observations of b coefficients for each variable interpersonal trust institutional trust importance of god in life overall analysis suggests that adding importance of god slightly weakens the effect of institutional trust 0751 rising its value by one unit will also result in decreasing odds ratio of occurring attitude centered on selfinterest by 25 40 in the case of interpersonal trust 0608 every 1point increase in the case of importance of god in life will result in 7 decrease in odds ratio of occurring the tested moral orientation 0934 in the final step educational level has been added to the model overall the model fits well to the data and shows significance allowing further analysis all four variables have a negative effect on chances to occur in the attitude that lacks prosocial traits this conclusion is drawn from the fact that coefficients of logistic regression for all independent variables are negative numbers interpersonal trust b 0417 institutional trust b 0320 importance of god b 0081 educational level b 0131 for every one unit increase in the level of education chances for occurrence of moral orientation centered on selfinterest decrease by 13 0878 adding educational level slightly modifies the odds ratio for the previously included variables now every one unit increase in interpersonal trust results in a 35 decrease of the likelihood of the tested moral orientation 0659 28 for confidence in institutions slightly improving its effect 0726 and 8 for importance of god 0922 in general the model explains almost 10 of variance of the dependent variable which is relatively satisfying for this type of regression discussion and conclusions the analysis showed that the most frequent type is the attitude away from people shared by nearly a half of polish society apart from the lower level of institutional trust no significant associations with sociocultural determinants have been detected in the analysis the second largest segment is created by representatives of attitudes against people in terms of sociocultural determinants this moral segment is characterized by a lower level of interpersonal and institutional trust a lower level of religiosity and education the least common moral orientation attitude towards people is shared by almost a quarter of society in poland in terms of sociocultural determinants individuals sharing such traits as higher level of interpersonal and institutional trust higher level of religiosity and living in larger cities are susceptible to this moral orientation sociological literature provides interpretations for the role of social and institutional trust affecting prosociality but in this case the positive effect on attitudes focused on prosociality might be a result of a specific sense of security that comes along with confidence in institutions prosocial activity requires trust in institutions in the sense that while obliging oneself to acts of charity external institutions secure ones own interest and resources leaving ones own matters aside for the sake of others would not be possible without an elementary level of trust that institutions responsible for security will create a stable environment and secure private properties or assets this interpretation explains why and how prosocial activity is possible in modernized and secularized societies interestingly enough institutional trust seems to increase the attitude towards people and decrease the attitude against people more than religion although it is necessary to report that variables were measured on different scales 5point and 10point scales this observation might lead to the conclusion that confidence in institutions as a motivator of prosocial activity belongs to the phenomenon described by robert bellah as civil religion in opposition to the classical concept of religion associated in poland with the catholic faith is the clash between these two types of religion possible when it comes to reign over polish souls the attitude towards people centered on the concern for others is undoubtedly much expected and needed in modern open societies the catholic concept of universal destination of goods reminds that those who possess goods will use them in a manner that benefits others since created goods belong to the whole humankind not sharing what one possesses is depriving others from what rightly belongs to all in one of his philosophical works karol wojtyła introduced the concept of the personalistic value of human act through which a man can fulfil himself and manifest his personalistic trait a special moment of manifesting personalistic traits in a man is participation together with others this involves moments of inner desire to be of aid to assist and benefit from togetherness when a man decides to participate to cooperate to attach himself voluntarily to a community then one might speak of transcending and truly fulfilling oneself now the question might be asked can religion still actively address the basic human needs and desires and if not why what kind of stimulus needs to be revived within the religious environment to help religion serve humans better without vivid religious factors civic religion might replace spiritual one in serving and answering basic needs of modern societies na podstawie dostępnych badań można stwierdzić że zaufanie instytucjonalne może stanowić istotny predyktor prospołeczności głównym celem niniejszego opracowania jest zbadanie współzależności pomiędzy typami zaufania a typami orientacji moralnych do od i przeciw ludziom kolejnym celem jest także określenie współzależności pomiędzy zaufaniem instytucjonalnym a orientacjami moralnymi z uwzględnieniem takich zmiennych jak religijność wykształcenie i wielkość miejscowości zamieszkania w artykule zaprezentowano analizę która pozwala uznać zaufanie interpersonalne oraz zaufanie instytucjonalne za alternatywne predyktory orientacji moralnych w porównaniu do innych bardziej ugruntowanych czynników tj religijność wyniki badań pozwalają stawiać pytanie o przyszłość religii w stabilnych i demokratycznych społeczeństwach której rola i funkcje mogą być kwestionowane słowa kluczowe prospołeczność zaufanie społeczne zaufanie instytucjonalne orientacje moralne religia cywilna

a b s t r a c t according to the latest research institutional trust may serve as a significant predictor of prosociality the main purpose of this article is to examine types of trust as predictors of moral attitudes towards away and against people another aim is to examine institutional trust as a predictor of moral attitudes in correlation to other significant predictors like religiousness education and size of town this paper presents an analysis in the course of which interpersonal and institutional trust has been confirmed as alternative potentially competing predictors of moral attitudes than other established variables eg religiousness the presented findings allow one to pose the question about the future of religion in stable democratic societies

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scientific and cultural organization 2015 socioeconomic status and ethnicity these factors can become barriers and act as determinants and restrict access to everyday science opportunities which dawson describes as a form of marginalization and oppression reproductionist models justify unequal access to scientific or cultural capital based on concepts such as habitus which establish a preponderance of economic cultural and scientific capital factors these factors determine the boundaries between social classes and stratify them in terms of what the family transfers this explains the need for inclusion this approach conceives education as a system that reproduces inequalities by rewarding the knowledge and behavior of the dominant classes and elites society needs to challenge reproductionist theories by promoting inclusive science communication that makes science available to all people equally with particular attention to vulnerable groups at risk of exclusion this article aims to contribute to this purpose by promoting inclusive science communication which seeks to identify practices that counteract the link between social class and preferences the aim is for all people to reach scientific excellence of scientific literacy therefore it takes as reference studies that show that students who start with a low cultural level in their family environment benefit more from the acquisition of cultural capital than those who already have a high cultural capital in their family this positively impacts academic success and is particularly powerful in lowachieving environments theoretical background 21 learning opportunities to overcome inequalities this study goes beyond reproduction approaches and helps to overcome the inequalities suffered by vulnerable groups encouraging high expectations one of the aspects that makes this process successful is high expectations because they change the perception that students have of themselves and have an impact on their academic trajectory studies of this process point out that it is a social one this framework explains how the aptitude for and attitude to learning depends on interactions with other people with whom the activity is shared therefore creating environments in which high expectations are paramount helps everybody build an identity that opens up new opportunities for improving their academic performance it also helps them to transform their attitudes to science and do away with ideas that science is for specific social and cultural groups studies on inclusive science communication point out the importance of high scientific quality in other words the activities are designed to be enjoyed and to give participants a role in communicating scientific evidence to develop strategies and actions to help them find solutions to their problems furthermore this scientific evidence has a social impact on peoples lives one example of this fact is the iphes in the local area program which tries to increase the participation of vulnerable groups while ensuring high scientific quality it is a program aimed at bringing educational activities on prehistory to students from disadvantaged backgrounds in the peripheral districts of the city of tarragona the program designs highlevel dissemination events by adapting the scientific content without losing the high quality and using a dialogic approach in the training sessions following this approach the aim is to create a participatory environment for adults and children based on a natural learning context which seeks to break the power relations between the scientist and the participants in this way the scientist contributes accumulated scientific knowledge about a reality addressed in the workshop while these contributions are taken up by the participants in a process in which the egalitarian and intersubjective dialog between the scientist and the participants promotes the construction and interpretation of this reality the program takes a great deal of trouble to adapt the content to the wide range of ages of the attendees while maintaining a high scientific level the workshops cover such topics as human evolution cultural and biological milestones hominids and social and technological advances the scientific level is high thanks to the material created by iphes researchers from the various research departments anthropology lithic technology molecular archeology paleobotany paleontology geology zooarchaeology cognition and palaeoclimate all sessions are led by an experimental archeologist who makes stone tools in the classroom produces fire and brings selfmade reproductions and replicas that the students can handle this sort of practical demonstration is quite common in prehistory outreach activities although the workshops in this program have the peculiarity that they adopt a dialogical approach the aim of which is to turn the occasion into a dialogical demonstration guided by the principles of equality inclusion an integrating vision and accompaniment in scientific reflection the iphes in the local area program is based on dialogic learning which has been widely demonstrated to improve childrens learning the european research program included crea funded by the european commissions sixth framework programme challenged the bourdesian model by implementing successful educational interventions and achieving outstanding scientific and social results it claims that successful educational actions allow children to develop their potential by building scientific capital the science workshop approach involves all these aspects which play an essential role the staging the reproductions and delivery the attitude of those in charge the vocabulary used and many other aids make the activity a genuinely educational experience 22 the program iphes in the local area casts and reproductions an integrative exhibition the iphes is a research institute in tarragona specializing in prehistory paleoecology and human evolution 1 one of its many 1 socialització iphes evoluciona outreach and teaching activities is iphes in schools the main program of educational scientific activities that attempts to respond to different school profiles in 2019 the program iphes in the local area was created to focus on schools classified by the department of education of the catalan government as being of special complexity 2 iphes in the local area acts in these schools to improve the situation with activities in prehistory for highlevel scientific dissemination with all the agents involved the iphes in the local area program provides unique science communication activities by combining high scientific quality with actions targeting vulnerable groups often excluded from science the program consists mainly of demonstrations that use many materials to make them a more interactive experience for the students to this end the person in charge is an experimental archeologist who uses his personal collection he brings between one and two hundred pieces for the demonstrations depending on the pedagogical approach the pieces include eight cast skulls of australopithecus and homo as a sample of human evolution all reproductions are handmade with dozens of stone tools designed to explain technological evolution for example a set of arrows a bow a spear and spearthrower or atlatl a bone flute and other musical instruments a pump drill among others have been chosen to reassess the intelligence of prehistoric populations most of them are carried in foam suitcases easy to transport and elegantly presented and are the focus of the demonstrations even though the stone tools are incredibly sharp and dangerous for children to handle the scientists carefully select some suitable tools so they show some flint tools with blunt edges and examine them to ensure no sensitive parts can cause any damage antlers bones and rocks are some sensory resources the public can touch the physical interaction is controlled by the team in charge and teaching staff and the reproductions are passed from hand to hand during the presentation the demonstrations also include resources that attempt to respond to the diverse needs of the student body to this end the scientist always carries five rocks with a unique texture a piece of elk antler with a delightful musky smell and a piece of juniperus oxicedrus wood these are used with pupils with hearing and visual impairments autism or other special needs these resources give them all a sensorial experience whatever their age and allow everyone to take part the scientists also work on integration by giving information about south america and showing reproductions from north africa many schools in tarragona are highly complex and have a large proportion of maghrebi descendants mainly from morocco this information about their places of origin is incredibly wellreceived by the students it often generates emotion when they recognize that prehistory is also essential in their country and culture the lithic arrowheads from north africa and south america are exceptionally creative and beautiful 2 by centres of special complexity we refer to the catalan norm that classify these centres according to indicators of social and economic disadvantage among others the activities of the public demonstrations are presented in terms of the main prehistoric periods the lower middle and upper paleolithic and the neolithic they can be chosen by the teachers of individual schools so that the subject matter can be dealt with beforehand as part of the school curriculum and the workshops function as curricular support successful scientific activities for all inclusive science communication aims to prioritize scientific analyses of actions and strategies that contribute to inclusion previous studies have shown that vulnerable groups can be attracted to science by implementing successful educational actions demonstrating that education has a more significant effect on scientific capital than socioeconomic status this is explained by understanding that the way science is approached and the extent to which students can relate to the topics presented can impact tastes preferences and skills the present article builds on studies already responding to the urgency of reframing science communication to embrace the shift toward a more inclusive form of communication that encourages people to engage with science for some authors this is a future that is already here so it is crucial to reaffirm those alternatives that advocate inclusive science communication by interrupting and transforming the processes of social reproduction and contributing to dismantling the structural inequalities embedded in our societies the spanish federation for science and technology a body that fosters the relationship between science and society has described the program by iphes as successful inclusive science communication in particular it points to its capacity to increase the participation of groups at risk of social exclusion which not only democratizes scientific knowledge but also generates better results thus increasing social cohesion the guidelines mentioned above towards inclusive science communication reflections on successful actions identifies four criteria for selecting and analyzing successful actions in inclusive science communication the first criterion aims to move toward the inclusion of those groups excluded by the approach to scientific knowledge or participation in science a european priority the second criterion requires actions to be based on scientific evidence of social impact or in other words that subset of scientific evidence that has already demonstrated social improvements social impact in science therefore refers to social improvements that respond to the needs and objectives of our societies this social impact comes about after research results have been disseminated and transferred the third requires policies strategies and actions to be replicable and sustainable this means that although they have been successful in one context they must be replicable and sustainable in others so successful actions are taken as the basis for successful policies or further actions furthermore the fourth criterion requires a bottomup approach that goes beyond the hierarchical figure of science and promotes the cocreation of scientific knowledge between researchers and citizens this type of approach ensures that citizens can participate in science thus increasing social impact and trust in science these criteria help to give impetus to the many sectors that need it and make the most important scientific advances available to the general public and society as a whole by working in this way science is brought closer to the public in a more effective way especially to all those who have been distanced from it for many different reasons materials and methods this study discusses the advantages of using a dialogical approach that does not underestimate the impact of the educational system and its community on overcoming inequalities and democratizing the right to access culture and scientific knowledge the objective is to analyze the impact of the workshops designed to popularize science looking for scientific excellence as part of the iphes in the local area program in three different urban schools classified as special complexity and assess how these workshops affect the interest in and appreciation of science among participants from vulnerable groups at risk of social exclusion having clarified the main objective the research question that guides this work is is developing scientific workshops with a dialogic approach an effective tool to bring science closer and awaken scientific interest in vulnerable educational contexts this communicative case study was carried out before and after the science communication workshops on the iphes in the local area program had been held in three schools in tarragona in 2019 each school participated in one session the aim was to analyze the impact the workshops have on the students participating in the program which takes place during school time and on the construction of scientific capital our analysis focuses on students aged between 10 and 13 but does not pretend to identify inequalities or compare the results from each school it is not a comparative case study this communicative case study follows the precepts of the communicative methodology cm is oriented toward social transformation and seeks to improve the living conditions of the people involved several competitive projects that have used this methodology have shown results of enormous social impact therefore the ce has recognized this methodology as one of the most suitable for working for and with vulnerable groups our claim is that scientific activities that tend toward the more inclusive communication of science can benefit vulnerable groups for gender ethnicity or socioeconomic status by increasing the interest and value of science the communicative orientation applies an egalitarian and intersubjective dialog among all participants this fact has facilitated and enhanced the workshop results in the schools because there is a creation of meaning when dialog is enhanced and scientific knowledge is built with them description of the scientific workshop the scientific workshop was held in one session in each of the three schools that participated in the study during the 6080 min of its duration an expert in scientific communication of science who is also an expert in lithic carving addresses content on prehistory and human evolution the topics covered include human evolution cultural and biological milestones hominids and the neolithic all of them are perfectly adapted to the age of the target students but with the indispensable condition of maintaining a high scientific level blocks of content that form part of the curricular subject matter are included in the social and natural sciences lessons of 5th and 6th grade of primary school before the workshop teachers are asked to present these contents in this way it is intended to connect and extend this knowledge with significant scientific data about prehistory paleoecology and human evolution despite being a playful session the academic content is maintained because it is aimed at vulnerable groups on the contrary the most uptodate information from international research on the topics covered is always provided the activity is carried out in the classroom or the playground as this is the students everyday space trying to make them feel comfortable and close to the scientist and thus reach out more the use of space is taken care of in great detail asking the teachers to make the students sit as an amphitheater children with special needs are offered the most suitable place to ensure that they can follow the activity closely accompanied by their educator so that heshe can provide the necessary support for their participation and interaction this arrangement allows the scientist to have direct eye contact with the students as heshe tries to be at the same level favoring a peertopeer dialog and nonverbal communication through the reading of glances that allows for detecting needs or interests among the participants the dialogical approach in which the session takes place creates a climate of closeness to science allowing participants to establish a dialog with the scientist by learning about his work and breaking down stereotypes that may be held toward scientists the scientist uses an egalitarian dialog that facilitates proximity between the scientist and the students while creating an environment of respect and curiosity toward science this aspect is essential to allow students to feel that scientific work is a possible option for them to this end the scientist asks open questions such as how do you imagine the first humans two million years ago or how do you imagine the prehistoric people questions that in turn help to elicit information from the group to address their concerns and interests better the workshops main objective is to encourage the collective construction of new meanings about prehistory as a science to do this it uses dialogical interactions to stimulate interest and curiosity among students throughout the session the elements that come into play to foster dialogical interaction are diverse first making tools during the workshop using the attraction of knapping provides the groups attention this is accompanied by the presentation of a personal collection of approximately two hundred handmade pieces these are pieces of various shapes colors and materials that can be manipulated in a controlled manner for example lithic arrowheads a bow a spear and spearthrower or atlatl bone flute and other musical instruments and bombdrill were chosen to impact and revalue the intelligence of prehistoric populations among the materials there are integrating resources that favor sensorial participation aimed at the great diversity of pupils such as five textured rocks a piece of elk antler with a pleasant amizclic smell and a piece of perfumed juniperus oxicedrus this is an interactive experience that aims to include all students second the use of specific questions marks in prehistory that are fundamental to explaining science and evolution one of them is what kind of parentage do chimpanzees and humans have or how do we know how old they are by formulating these questions the aim is to arouse interest in finding out how scientists know to show prehistory as a science it shows how the age of a site is dated by offering accurate data on a scientific basis the resource the questions is linked to two very current issues on which the aim is to provide knowledge from prehistory gender and multiculturalism regarding gender by showing prehistory as a stage of humanity in which there is no gender the activity seeks to provide examples in which women and girls are more visible to society for example the use of images of a neanderthal girl or a woman making a spear it also shows how new dna studies make it possible to identify gender more clearly and to find kinship within the femalemale marriage migration system etc another example of thoughtprovoking interrogations is asking about human origins and africa at this point in the session the scientist opens a window to formulating hypotheses that he does not try to resolve but instead answers with more questions this helps to stimulate curiosity for knowledge and to activate the curiosity to construct a more approximate vision of the first humans deduced by the pupils through the questions formulated by the scientist this leads to dealing with the physical and cultural differences between the worlds populations one of the most popular topics being schools located in multicultural neighborhoods with significant cultural religious linguistic and ethnic diversity which becomes an excellent opportunity for learning that always involves managing human origins with extreme respect finally another component is the interest per se in prehistoric peoples related to the learning process of the planet the formation of the human being the keys that prehistory offers to explain some issues of life in society coexistence as part of human evolution or technological devices and skills in survival and social evolution the degree of attraction that prehistory plays with provides the ability to attract the attention even of pupils with adverse educational backgrounds it supports the idea that prehistoric science can generate a perfect environment to help pupils in many aspects of their lives changing their relationship with science and contributing to overcoming school dropout rates even to overcome discriminatory patterns be it gender or ethnicity or to reject any violent behavior in brief these actions have already been carried out in the framework of other projects demonstrating their internationally recognized impact the results of which have been published in scientific journals that highlight the quality of the actions developed and the relevance of being implemented in vulnerable groups thus proving to be a sustainable project and replicable in other spaces such as residential centers for educational activities taken on institutionalized children study participants a common feature of the workshops is that they are all designed for students who are highly vulnerable because of their family profile or the context in which they find themselves therefore three schools with a high percentage of vulnerable students were chosen in three different areas of the city of tarragona they all have numerous highly vulnerable students at risk of social exclusion in total 117 students participated the three schools are in different parts of the city one in the center and two in suburban areas of low socioeconomic status and high risk of social exclusion the areas where the schools are located are characterized by ethnic and religious diversity as reflected in the data obtained from the groups participating in the study the distribution of participation between sexes was equal with 538 of males school 1 this school is located in the center of the city of tarragona and has a wide diversity of pupils and family types about 15 of the pupils are foreigners of various nationalities including those from latin america school 2 this school is located on the outskirts of tarragona it has a wide range of pupils mainly immigrants from other countries the most abundant population is from morocco but there are also students from other parts of africa central america and europe school 3 this school is located in a peripheral neighborhood of tarragona and at least 50 of its pupils come from different cultural backgrounds before being involved in the research all participants and their families were informed by the school management teams researchers provided all ethically required information to the management teams including the main objectives of the activities and how all information regarding the participants would be anonymous in that way first the school management teams informed all families regarding the study and later researchers explained everything to the students data collection and analysis a questionnaire was used to collect information from all the people who participated in the workshops and analyze how the project impacted them it was designed based on the theoretical review carried out in the study and reviewed and validated by an advisory board the advisory board plays a role in communicative research methodology and its members contribute knowledge and review documents this study consisted of two scientists involved in science communication one of whom was directly responsible for the iphes in the local area program its primary function was to validate the questionnaire used in the research the questionnaire is structured in two parts the first collects sociodemographic data on the students participating in the workshops the second focuses on compiling content that identifies the workshops impact on the people who have taken part the questions follow a rating scale in which respondents were asked to select the option that best reflected their opinion on the question strongly disagree disagree agree and strongly agree the central aspect is the personal perception of science so that the attitudes it inspires in the participating students can be identified it also collects information on interests and preferences in scientific activities and on the valuation of scientific knowledge each of these aspects is reflected in the variables reported in table 2 which were defined after the theoretical review had been analyzed specified in the form of various items and agreed on with the advisory board as set out in table 3 for the statistical analysis spss was used to quantify the responses obtained in both the pretest and the posttest and identify the most remarkable changes that occurred after participation in the science workshop session thus allowing a descriptive analysis of the impact on the participants improved interest in and appreciation of science the posttest was immediately implemented after the workshop this is not a limitation but with another one session and more time it could be reached a longerterm impact it is important to note here the role played by the advisory board in validating the questionnaire since the comments they provided were used to establish the blocks of content directly related to the main variables of the study the results faithfully reflect this previous work on the data collection instrument and these essential study variables results three main results have been obtained change in personal expectations toward science increased interest in science increased appreciation of scientific knowledge signs of change in personal expectations toward science the results indicate a change in personal expectations toward science in particular the participants state that they are more likely to become scientists because their close and direct contact with a scientist in the workshops has encouraged them to consider a career in science at the same time the results show that becoming a scientist requires considerable effort which can be seen in the lower posttest value when the participants were asked whether they could work as a scientist key to these results is the attitude of the scientists who try to remain on the same level as the pupils so as not to hierarchize the relationship the use of jokes smiles expressive faces mimicry and a clownlike demeanor are critical points in creating a good atmosphere at first students ask whether the scientist has made the reproductions this is often the case because they want to identify whether they are bought or made by themselves at first the scientists usually answer the same two questions in this order are the reproductions and replicas authentic did you make them yourself students need to recognize authenticity and expertise and like to talk to scientists in general they manage to do this because the scientists control the excitement but allow conversation among the students as they finish setting the scene following the precepts of an egalitarian and intersubjective dialog among all participants at this point they reflect on their pupils and try to spot whether they are irreverent curious hyperactive withdrawn or above all need more attention such as those who retreat to the back are more solitary or have special needs finally variable description interest in and preference for science positive attitude to activities with scientific content perception and appreciation of science interaction with science relationship with science and shared experiences constructed images about science and the importance of the knowledge it brings to society personal expectations toward science aspirations to become a scientist variables items interest in and preference for science i like the subject of the natural environment i like reading books and magazines about science i like it when we do science experiments i would like to do more hours in the natural environment i am interested in observing and learning about how nature works i would like to go on a field trip to a museum i like to watch science tv programs i like to do activities about animals nature tools etc perception and appreciation of science interaction with science i am interested in the history of my territory i am interested in watching videos on the internet to learn more about science i tell my parents about the activities we do at school i want to attend a talk or presentation on science by a researcher i think that studying the past of humans is important when they sit in a chair surrounded by many exciting things in front of a group of pupils each interested for different reasons sitting in a circle around the materials the expert brought created an egalitarian atmosphere the person leading the workshop encouraged an egalitarian dialog with all the students showed them every one of the pieces he brought with him and answered all the questions they asked the expert sought to motivate participation even among those who usually did not participate due to shyness fear or any other reason he had them take the materials and they helped him by showing them to the others while he explained how they worked signs of increased interest in science one of the iphes in the local area program topics that helps awaken interest in science is the discussion of the skin color of the first homo sapiens and especially of the last european huntergatherers palaeogenomic dna studies provide valuable information on the appearance of prehistoric peoples and evidence that the last huntergatherers in europe were darkskinned with a high frequency of blue eyes such statements as if we all came from africa we were darkskinned have a substantial impact on the demonstration and sometimes encourage changes in views of migration and different understandings of human origins and diversity these themes lead to exciting discussions about racism with the students one of the rules to follow when dealing with reactions to such statements is to manage the dialog very carefully by bringing students into the dialog and intervening only occasionally to provide scientific information or to correct a statement or description a comparison of the data provided by pupils in the pretest and the posttest shows that the analysis of the variables on interest in and preference for science was positive some of the items have more remarkable results interest in scientific activities or the importance of accessing scientific knowledge to understand our past better almost all of the posttest results are better than the pretest results indicating that the sessions positively impact and increase interest and preference for science evidence of increasing appreciation of science and scientific knowledge there is an improvement in those items related to the importance given to science the valuation of scientific knowledge and positive attitudes toward science such as motivation or considering it fun and necessary for the question when we talk about science what comes to mind the comparison shows that posttest results are higher than pretest results and particularly that it is perceived as necessary and fun these data show that after doing the scientific activities practically half of the students perceive them as necessary and fun it is also important to point out that the value of science as a form of knowledge increased from 325 in the pretest to 444 in the posttest finally the value of the importance of science increased from 687 to 718 as shown in table 6 the activities on the iphes in the local area program on prehistory explain aspects of life in society and coexistence and show the value of scientific knowledge scientists try to be inclusive in all senses and select content to provide a complete education for example they discuss the human brain and the enormous complexity of assessing intelligence as a multifactorial fact they use the differences in the capacity of the human brain and its replicas to address this issue they explain scientific conclusions about the evolution of the human brain but also specific cases about the value of any intelligence this is particularly important to the scientists who teach the sessions and give a broad conception of cognitive diversity likewise the fact that there is usually considerable cultural religious linguistic and ethnic diversity among the participants at all the iphes in the local area sessions is an excellent opportunity to show that the evolution of modern humans is complex longlasting and planetwide from africa to asia to europe to the americas the homo sapiens adventure can be used to show the emergence and development of the differences and the enormous similarities between humans today bringing science closer to everyday reality as the iphes in the local area program does causes the negative items on the questionnaire to be conceptualized as less negative as seen in table 7 the pretest values are already low but all the posttest values are lower in particular the perception of anxiety is halved it should also be noted that after the scientific activities have been carried out the pupils rate the scientific topic as more complex partly because they have a clearer perception of the difficulty that scientific activity can entail when they see it being carried out live this change in how science is perceived also has an impact on how it is assessed the most remarkable of these items are the increase in the initiative to share the science workshop experiences with their families and the importance of scientific knowledge for society in particular the importance of studying the past of humans as shown in table 8 this article discusses the impact of the science communication workshops on the iphes in the local area program designed to bring students at risk of social exclusion in three schools in tarragona into contact with science the evidence shows that school interventions have led to an increase in interest in scientific activities and learning science as previous research has shown highquality science communication activities contribute to building scientific capital and positively impact communities of low socioeconomic status that have traditionally been excluded from this type of learning activities this is key to arousing interest and motivating people to engage with scientific knowledge working in this way can reduce the barriers that discriminate and oppress vulnerable groups and prevent them from accessing scientific knowledge the study also shows that the children who participated in the science workshops improved their perception and appreciation of science previous studies have determined that dialog on equal terms with scientists in science communication activities arouses peoples interest in science by building relationships of trust and security and minimizing social inequalities communicating science in this way makes participants see science as more genuine reveals the complexity of scientific knowledge and shows them the importance of science in society the present research demonstrates that communicative science workshops can increase preferences for scientific activities by increasing the appreciation of science and scientific knowledge in vulnerable groups two fundamental components have played a decisive role in obtaining this increased interest in scientific activities the scientific evidence on which the whole process was based and the process itself since it revealed a dialogic learning process 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 approval was not required for the study involving humans in accordance with the local legislation and institutional requirements written informed consent to participate in this study was not required from the participants or their legal guardiansnext of kin in accordance with the national legislation and institutional requirements the educational centers involved in the fieldwork informed the participants families about the project in memoriam we dedicate this article to miquel guardiola who carried out all the training sessions with the children in the schools and who has promoted this line of research he visualized and worked on the beginning of this article that we now publish miquel although you are not physically with us your work and your desire to improve the lives of all the children with whom you have interacted will always be with us 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

the literature shows not only that science communication excludes the most vulnerable groups in society but also that it is of the utmost importance to make it more inclusive and available to all citizens however the inclusive communication experiences that are having some impact on society by including vulnerable groups have yet to cover all aspects of the issue this article shows the positive results of scientific workshops that take a dialogical approach from researchers from the institute of human palaeoecology and social evolution iphes the workshops on the iphes in the local area program are designed to communicate science looking for scientific excellence in urban centers that are of special complexity the data were collected using preand posttest questionnaires given to 117 pupils from three primary schools where the science workshops were held the data analysis shows that after the workshops participants had a greater interest in and appreciation of science

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the primary objective of this study this study examines the impact of technological progress on family wellbeing through the perspectives of millennial women as key contributors to family dynamics millennial women play a vital role in nurturing the physical mental and emotional health of their families with the rapid advancements in technology millennial women have witnessed transformative changes in healthcare communication and lifestyle choices this interdisciplinary study aims to shed light on the relationship between millennial women and the implications of technological progress on family wellbeing millennial women represent a generation immersed in a rapidly evolving technological landscape they have firsthand experience of the profound influence of technology in domains such as healthcare communication and personal development as primary caregivers and decisionmakers within their families millennial women play a crucial role in shaping family wellbeing understanding their experiences attitudes and behaviours towards technology provides valuable insights into the intricate interplay between technology and family dynamics the primary objective of this study is to explore the impact of technological progress on family wellbeing from the perspectives of millennial women by examining their experiences attitudes and perceptions we aim to uncover the multifaceted ways in which technology affects various dimensions of family life including physical health mental wellbeing communication patterns and lifestyle choices employing an interdisciplinary approach drawing from disciplines such as sociology psychology and health sciences this study seeks to provide a comprehensive understanding of the relationship between millennial women technological progress and family wellbeing this research contributes to the existing body of knowledge on the implications of technological progress on family dynamics providing valuable insights for policymakers practitioners and researchers the findings will inform strategies and initiatives aimed at promoting family wellbeing in the context of a technologically advancing society methodological approach to fulfil the objectives of this study qualitative research was conducted as part of the authors doctoral degree programme the data collection period encompassed a span of three months starting from may 2021 and concluding in july 2021 the study involved a group of 31 millennial women respondents who were based in malaysia the chosen duration and methodology were influenced by the prevailing circumstances of the covid19 pandemic which necessitated the use of remote data collection methods notably the utilisation of google forms as a platform for conducting webbased written interviews was an innovative aspect of this research as highlighted by through the utilisation of this underutilised tool the study successfully collected rich and insightful responses from the participants furthermore a qualitative expert validated the research instruments ensuring their reliability and credibility throughout the analysis process continuous discussions among the researchers were held with each member contributing their distinct expertise to enhance the overall credibility of the findings the study also incorporated the recommended approach of abstraction and interpretation during the analysis as proposed by this iterative process involved meticulous revisions comprehensive discussions on codes and categories and an unwavering commitment to ensuring the credibility and rigour of the studys outcomes findings and discussions i millennial womens perspective on the vitality of overall health in the implications of technological progress on societal advancement millennial women occupy a unique position in contemporary society assuming multiple roles that shape family dynamics understanding the importance of overall health from their perspective is essential as it directly impacts the wellbeing of their families this study aims to explore how technological progress have influenced family wellbeing considering the perspectives of millennial women technology have facilitated improved access to healthcare for millennial women and their families telemedicine and virtual health platforms offer convenient and remote healthcare services enabling individuals to seek medical advice and consultations from the comfort of their homes moreover aipowered health monitoring devices and wearable technologies empower millennial women to proactively manage their health enabling early detection of potential health issues and timely interventions the recognition of mental healths significance in family wellbeing has grown significantly in recent years aidriven mental health platforms and applications provide personalised support guidance and therapeutic interventions through enhancing the accessibility of mental health resources and mitigating the stigma associated with seeking assistance for psychological wellbeing these advancements contribute to the amelioration of overall health within families ai and technological progress have revolutionised lifestyle choices particularly in the domains of nutrition fitness and selfcare millennial women can access aipowered applications that offer personalised dietary recommendations track fitness progress and provide guidance for maintaining healthy habits these technological advancements empower millennial women to make informed choices that promote overall health for themselves and their families reproductive health and family planning are integral components of overall health for millennial women aidriven fertility tracking applications and reproductive health resources offer accurate insights guidance and support enabling individuals and couples to make informed decisions these advancements contribute to improved family planning outcomes and overall wellbeing for millennial women and their families whilst ai and technological progress have brought numerous benefits ethical considerations and challenges must be addressed issues such as data privacy algorithm bias and equitable access to technology require careful attention to ensure that the benefits of ai and technology are available to all and do not exacerbate existing disparities in family wellbeing the perspectives of millennial women shed light on the significance of overall health in family wellbeing ai and technological progress have provided millennial women with tools resources and opportunities to enhance overall health and positively influence family wellbeing the advancements in healthcare access mental health support healthy lifestyle choices and reproductive health empowerment demonstrate the potential benefits of ai and technology in improving family wellbeing it is imperative for society to foster responsible integration of ai and technology addressing ethical considerations and ensuring equitable access to maximise the benefits for millennial women and their families through recognising the importance of overall health and harnessing the potential of ai and technological progress societies can strive to cultivate healthier and more thriving families drawing on the perspectives through the significance of overall health in family wellbeing it is evident that comprehensive health is considered a crucial element by the informants the informants definition of family wellbeing emphasises the inclusion of physical health mental health and emotional health as integral dimensions therefore within the context of family wellbeing the achievement of optimal physical mental and emotional health is considered essential the participants expressed the following viewpoints a healthy and happy family health health n happiness among family members it is important to make sure everyone is working towards living a healthy lifestyle we must always remind each other mental and physical health family wellbeing entails the satisfaction of basic needs positive mental health the attainment of happiness physical wellness financial stability and a sense of purpose in life harmony healthy happy it is noteworthy that physical health emerges as the primary element highlighted by several informants including lam chen fenfang fatimah hanisah and yuhainis these informants emphasise the paramount importance of physical health in promoting family wellbeing their perspective suggests that a decline in physical health can pose a threat to family harmony as it may impose limitations on various aspects such as engaging in activities with family members and straining family finances the informants recognition of physical health as a foundational component of family wellbeing aligns with the broader discourse on the significance of overall health it is consistent with the understanding that physical health forms the basis for individuals overall wellbeing and functioning furthermore the informants observations highlight the potential consequences that compromised physical health can have on family dynamics and the overall welfare of the family unit this perspective resonates with the exploration of ai and technological progress discussed earlier as these advancements have facilitated improved access to healthcare and promoted proactive health management the integration of aidriven health monitoring devices wearable technologies and telemedicine platforms has empowered individuals including millennial women to prioritise and enhance their physical health through the utilisation of these technologies individuals are empowered to proactively manage their wellbeing by engaging in early detection of potential health issues seeking remote medical advice and implementing the recommendations proposed by in light of the informants views and the advancements in technology heath et al it becomes evident that promoting and maintaining physical health is essential for family wellbeing a holistic approach to family wellbeing should encompass efforts to support and optimise physical health within the family unit addressing the challenges and considerations associated with technological progress such as ethical concerns and equitable access societies can harness the potential of these advancements to foster healthier and more thriving families overall the informants perspectives emphasise the crucial role of physical health in family wellbeing aligning with the broader recognition of the significance of overall health the integration of ai and technological progress further strengthens the ability to promote physical health within families contributing to enhanced family wellbeing and harmony ii leveraging technological advancements for financial support and planning among millennial women the inclusion of financial support emerges as the second element in defining family wellbeing indicating its significance as perceived by the informant this perspective emphasises the importance of economic aspects within the overall wellbeing of the family specifically the informants definition of family wellbeing encompasses achievements in terms of stable finances and financial support a respondent echoed similar sentiment expressing her perspectives as follows family wellbeing entails the satisfaction of basic needs positive mental health the attainment of happiness physical wellness financial stability and a sense of purpose in life in the context of millennial women and technological advancements the role of financial support takes on added significance with the rise of digital platforms fintech innovations and mobile banking applications millennial women have gained access to a wide array of tools and resources for managing their finances effectively these technological advancements have empowered millennial women to take control of their financial wellbeing enabling them to budget track expenses save invest and plan for the future more efficiently millennial women can create a significant impact on the overall wellbeing of their families by harnessing the potential of these technological resources to enhance their financial stability furthermore the integration of technology has also revolutionised the way financial support is provided within families platforms such as peertopeer lending crowdfunding and digital payment systems have expanded the options for obtaining financial support making it more accessible and convenient this allows millennial women to explore alternative sources of funding start their own businesses or support their families financially in innovative ways technological advancements have thus played a crucial role in facilitating financial support and fostering economic wellbeing among millennial women thereby contributing to the broader concept of family wellbeing in summary the interplay between millennial women technological advancements and financial support is transforming the landscape of family wellbeing the integration of technology provides millennial women with the tools resources and opportunities to take charge of their financial health positively impacting their families overall wellbeing as society continues to embrace technological advancements it is essential to recognise and harness their potential in promoting financial support and planning among millennial women ultimately fostering thriving and resilient families iii fostering empathy and support through technology millennial womens perspective empathy support and understanding are vital components of maintaining healthy relationships and promoting overall wellbeing within families millennial women as key members of the family unit have recognised the significance of these elements in fostering harmonious family dynamics with the advancements in technology millennial women have found new avenues to cultivate empathy offer support and enhance understanding within their families according to the informants viewpoints a prosperous family is characterised by the practice of mutual respect encompassing respect for family members irrespective of their age and honoring their decisions and choices without undue interference every member of the family loves each other loves and respects each other a family that respects each other in the digital age technology has revolutionised the way millennial women connect with their loved ones and provide support social media platforms messaging apps and video conferencing have empowered millennial women to bridge geographical distances and maintain strong connections with their family members these digital tools enable them to engage in meaningful conversations share experiences and express empathy and understanding fostering a sense of closeness and support able to love care and understand each other happy family… understanding… honesty… always be there for each other trust one another and check on each other at all time to complement each other and understand one another a harmonious family understands each other helps each other and tolerates each other understanding compatibility and effective communication as highlighted by respondents for the next element huiyin alia kasimah shima damia and salamah concur that a prosperous family should be characterised by a culture of supporting one another this culture manifests as an expression of love through the unwavering support of every family members decisions and activities these platforms provide a safe space where millennial women can share their challenges seek support from others who may have faced similar situations and offer empathy to those in need the power of virtual communities lies in their ability to bring together individuals from diverse backgrounds and experiences fostering a sense of understanding and support togetherness through thick and thin family wellbeing for me is the willingness to tolerate to cope and to be there for each other among family members and care towards any aspects that cause concerns it is also a condition where selflessness is practiced in order to achieve harmonious household family members who can live peacefully and harmoniously cooperate in everything always stay in touch with each other and provide physical and mental support to one another complementing each other and understanding a harmonious family understands each other helps each other and tolerates each other trust and support technological advancements have also revolutionised the way millennial women can access professional support services online therapy platforms and mental health apps have made it more convenient for them to seek therapy or counseling promoting their emotional wellbeing these digital resources offer a range of therapeutic tools selfhelp resources and remote counseling options empowering millennial women to prioritise their mental health and seek the support they need additionally technology has played a significant role in promoting tolerance and inclusivity among millennial women online platforms have become spaces for discussing and raising awareness about social issues promoting diversity and challenging societal norms millennial women have utilised these digital spaces to advocate for equal rights address systemic injustices and foster understanding and acceptance among individuals of different backgrounds in conclusion technology has provided millennial women with powerful tools to foster empathy support and understanding within their families through digital platforms they can connect with their loved ones seek support from virtual communities access professional help and promote tolerance and inclusivity embracing these technological advancements millennial women can create positive impacts on their families wellbeing nurturing healthier relationships and contributing to a more empathetic and supportive society iv nurturing strong connections with technology the power of effective communication for millennial women in todays fastpaced digital era where technology has revolutionised the way we connect and communicate the importance of effective communication in promoting family wellbeing cannot be underestimated building and maintaining strong connections among family members are vital for fostering harmonious relationships and cultivating a supportive environment through the perspective of millennial women this research explores the profound impact of effective communication on family wellbeing shedding light on its transformative potential by delving into the insights provided by laila melissa and amalina who emphasise the role of communication in defining family wellbeing we gain a deeper understanding of its significance these informants recognise that good communication is an essential element for promoting family wellbeing as expressed in their statements good communication between family members understanding compatibility and effective communication family who are open for discussions communication serves as the foundational environment through which family members interact bringing their identities and communication patterns into the broader community as assessed by this environment instills confidence and fosters personal growth nurturing individuals abilities and creativity which contribute positively to society cultivating openness in bilateral relations accepting both the positive and negative aspects of parties involved or discussed topics is integral to effective communication guidance and practice in organizing speech intonation and body language start at home equipping individuals with the skills needed to navigate challenges within society sari et al further reveal that communication reflects ones personal character and can be developed effective communication encompasses various mediums from traditional facetoface interactions to cuttingedge technologies it transcends physical boundaries empowering millennial women to connect with family members regardless of geographical distances voice calls video calls letters and digital platforms serve as conduits for meaningful exchanges facilitating continuous connection and unwavering support however it is crucial to underscore that effective communication must be rooted in positive elements such as a culture of respect the wellbeing of a family depends not only on the frequency of communication but also on the quality and depth of interactions open and honest dialogue active listening empathy and understanding form the pillars of effective communication fostering an environment conducive to personal and collective growth mutual support and emotional wellbeing this research illuminates the profound impact of effective communication within the context of millennial women offering valuable insights into its transformative power it underscores the essential role that communication plays in nurturing strong connections within families and enhancing overall wellbeing through a comprehensive examination of the dynamics and effects of effective communication we aim to uncover strategies and approaches that empower millennial women to cultivate thriving family relationships and contribute to their personal growth in conclusion the power of effective communication cannot be underestimated in the pursuit of family wellbeing as millennial women navigate the digital landscape they have a unique opportunity to leverage communication tools and platforms to foster strong connections with their families through embracing positive communication practices and fostering a culture of respect millennial women play a pivotal role in cultivating harmonious relationships and creating an environment of love understanding and unwavering support within their families v exploring the techinfused faith the significance of tranquility and harmony in family wellbeing tranquility and harmony hold profound importance in the realm of family wellbeing intertwining with the techinfused faith embraced by millennial women jia li sarah and kasimah distinguished voices in the discourse shed light on the essence of tranquility and harmony as crucial components of a fulfilling religious lifestyle living in peace and harmony family members can experience their everyday lives within a conventional serene and secure environment family members who can coexist in peace and harmony collaborate seamlessly in all endeavors maintain constant communication and provide mutual physical and emotional support the pursuit of peace within the family serves as a catalyst for peace of mind among its members fostering an environment conducive to holistic growth and personal fulfillment in this context tranquility emanates from the alignment of spiritual and physical needs acting as a catalyst for sound decisionmaking and the overall wellbeing of the family unit vi nurturing spiritual and physical needs a prerequisite for peace of mind recognizing the multidimensional nature of human existence millennial women navigate the intersection of technology religious lifestyle and their quest for tranquility understanding that attending to the spiritual and physical needs of each individual within the family is imperative for the attainment of genuine peace of mind citing from carsons study conducted in 2016 it becomes evident that in the contemporary digital age technology functions as a bridge facilitating the connection between millennial women and spiritual resources this technological interface provides new and unique opportunities for individuals to engage with their faith fostering a deep sense of spirituality in their daily lives from digital prayer apps to online religious communities technology empowers millennial women to fulfill their religious duties and nourish their souls simultaneously the pursuit of physical wellbeing plays a vital role in nurturing tranquility and harmony within the family millennial women embrace technological advancements to enhance their physical health integrating fitness trackers wellness apps and digital resources into their routines by prioritizing their wellbeing they lay the foundation for a peaceful and thriving family environment as highlighted in the findings below religion and lifestyle such as practicing honesty are integral to the definition of family wellbeing expressed by informant prisha honest communication and ethical behavior are considered noble attitudes that should be embraced by every family member fostering trust and harmony within the family unit happy family… understanding… honesty… always be there for each other trust one another and check on each other at all time religion is a powerful force that permeates human life shaping individual perspectives and gaining social acceptance it is the belief in an extraordinary power rooted in the core of societys acceptance similarly alavi et al define religion as a discipline that educates the soul and promotes internal spiritual growth encouraging individuals to connect with a higher power vii embracing the techinfused faith a harmonious blend the intersection of technology religious lifestyle and the pursuit of tranquillity represents a harmonious blend that plays a pivotal role in the wellbeing of millennial women and their families throughout this study the findings have highlighted the significant contribution of religious beliefs and practices to family wellbeing emphasising the importance of fostering calmness and harmony within the family informants jia li sarah and kasimah along with informant prisha who underscores the enduring value of honesty align with previous research conducted by this research suggests that religion and lifestyle provide a profound sense of meaning and purpose to human existence strengthening goals and values that permeate all aspects of life in this digital age technology serves as a powerful tool that enables millennial women to enhance their spiritual journey and engage more deeply with their faith offering novel avenues for connection and participation in religious activities technology provides convenient access to spiritual resources fostering a deep sense of spirituality in their daily lives from digital prayer apps to online religious communities millennial women can bridge the gap between their digital lifestyles and their religious aspirations cultivating a techinfused faith that enriches their spiritual experiences furthermore the pursuit of tranquillity and wellbeing extends beyond the spiritual realm to encompass the physical dimension millennial women recognise the importance of attending to the physical needs of each family member as a foundational element for a peaceful and thriving family environment embracing technological advancements that promote physical health such as fitness trackers wellness apps and digital resources millennial women prioritise their physical wellbeing thereby enhancing their own health and creating an environment that supports the wellbeing of their family members in conclusion the harmonious blend of technology religious lifestyle and the pursuit of tranquillity holds tremendous potential for the wellbeing of millennial women and their families attending to the spiritual and physical needs of each family member and embracing positive religious practices millennial women create an environment of peace harmony and unwavering support within their families technology serves as a powerful tool in their spiritual journey facilitating engagement with their faith while a commitment to physical wellbeing strengthens the foundation for a thriving family unit ultimately this holistic approach fosters genuine peace of mind and contributes to the overall wellbeing of millennial women and their families viii techinfused love happiness and harmony empowering millennial women with technology in the rapidly evolving digital landscape technology has become an integral part of our lives shaping the way we connect communicate and experience the world for millennial women technology holds immense potential in enhancing various aspects of their lives including love happiness and harmony in this era of techinfused possibilities millennial women are leveraging the power of technology to empower themselves and cultivate a sense of fulfillment and balance in their personal and relational spheres from dating apps that facilitate meaningful connections to mindfulness apps that promote emotional wellbeing technology serves as a catalyst for love happiness and harmony in the lives of millennial women according to the informant a prosperous family should be defined as a family that practices mutual love happiness and harmony in other words the informant defined family wellbeing as the possession of these three internal feelings by each family member love is the first element expressed by li hua and siti the following lists the responses of all these informants in general love is an element that every individual needs more than material possessions the love received from family members should be the first love received by each individual able to love care and understand each other each member of the family loves and respects one another as shared by multiple informants the notion of a prosperous family encompasses the presence of happiness in everyday life this happiness transcends material possessions and is rooted in the unwavering support care and affection demonstrated by family members towards one another a healthy and happy family health and happiness among family members it is important to make sure everyone is working towards living a healthy lifestyle we must always remind each other being happy happy family… understanding… honesty… always be there for each other trust one another and check on each other at all time family wellbeing entails experiencing happiness together as a family family wellbeing entails the satisfaction of basic needs positive mental health the attainment of happiness physical wellness financial stability and a sense of purpose in life happy free mind harmony healthy happy happy family subsequently jia li cathalina kasimah damia yuhainis and rozlinda highlighted the significance of harmony in defining family wellbeing harmony can be interpreted as cultivating a serene and thriving familial atmosphere however a harmonious family does not imply the absence of conflicts rather it refers to families that approach conflicts with composure openness and generosity seeking appropriate solutions to preserve family harmony living in peace and harmony harmonious family ties family members who are able to live in peace and harmony collaborate in all aspects of life they maintain constant communication offering both physical and emotional support to one another a harmonious family is one where its members understand support and show tolerance towards one another harmony healthy happy harmony within the family a harmonious and happy family is built upon the foundation of love support and mutual respect among its members in this study millennial women have identified love happiness and a harmonious life as crucial elements for family wellbeing they recognise that the wellbeing of the family serves as a cornerstone for societal productivity contributing to the development of a strong and stable country the role of parents in nurturing love happiness and harmony within the home cannot be overstated as affirmed by informants such as li hua siti lam prisha emma yuhainis asnah jia li and others within the context of building a prosperous family each family members active participation in exercising their rights and responsibilities is of paramount importance through cooperation and gratitude they cultivate a culture of love and care bridging the gap towards a harmonious and flourishing family life the practice of mutual love and support within families serves as a guiding path towards a harmonious and prosperous life furthermore this paper delves into the transformative impact of technology on the pursuit of love happiness and harmony by millennial women it highlights the opportunities and challenges that arise as they harness technology to empower themselves and facilitate meaningful connections by embracing digital tools and platforms millennial women can nurture fulfilling relationships promote emotional wellbeing and create harmonious environments within their families the convergence of technology and these essential elements of love happiness and harmony opens up new possibilities for millennial women enabling them to embark on a journey of personal growth empowerment and the creation of joyful and harmonious lives ix unveiling the purpose empowering millennial women with technology for an open mind and meaningful life in the everevolving digital landscape technology has become an integral aspect of our lives shaping the way we perceive and navigate the world around us for millennial women technology holds immense potential in not only expanding their horizons but also in deepening their understanding of the purpose of life and fostering an open mind in this era of techinfused possibilities millennial women are utilising the power of technology to empower themselves cultivate a sense of purpose and embrace a more openminded approach towards lifes complexities this paper delves into the transformative impact of technology on millennial womens quest for purpose and the cultivation of an open mind it explores the opportunities and challenges presented by technology in their journey towards selfdiscovery personal growth and the pursuit of a meaningful and fulfilling life through harnessing the capabilities of technology millennial women have the opportunity to embark on a journey of exploration engaging in selfreflection and developing a broader comprehension of the world this transformative path enables them to discover the purpose of life and embrace a receptive and open mindset moreover the informants viewpoint regarding family wellbeing underscores the importance of integrating life purpose and cultivating an open mind hanisah specifically articulates the profound value of having a clear purpose in life as evidenced by the insights shared in the following the clarity of direction and collective alignment of family members towards a shared objective exemplify the essence of life purpose this shared sense of purpose establishes a framework that enables each family member to chart their own course minimizing potential conflicts and fostering the holistic wellbeing of the family unit family wellbeing entails the satisfaction of basic needs positive mental health the attainment of happiness physical wellness financial stability and a sense of purpose in life cultivating an openness of mind is closely tied to fostering a culture of respect that embraces the diverse perspectives suggestions choices and opinions of all family members this inclusive approach not only prevents conflicts but also contributes to the overall wellbeing of the family rohani further emphasises the significance of an open mind as an essential element in defining family wellbeing openmindedness can be understood as an individuals capacity to accept and consider the viewpoints suggestions choices and opinions put forth by other family members such openness enables individuals to engage in constructive dialogue explore novel perspectives and enhance existing solutions or options when necessary happy free mind the advancement and development of a society are determined by the extent of progress and growth experienced in various aspects of life encompassing both the physical and spiritual dimensions the level of progress can be assessed by comparing the current situation to previous benchmarks within the family unit individual achievements are reflected in an increasingly improved standard of living that benefits not only the individuals themselves but also contributes to the development of the broader community therefore the focus of this study centers on the consistency of efforts made by family members to continually progress aiming for development and a better future as these endeavors significantly contribute to the overall wellbeing of the family in the pursuit of societal advancement and development progress and growth across various dimensions of life encompassing the physical and spiritual realms play a vital role evaluating the level of progress involves comparing the current situation to past benchmarks with individual achievements within the family unit contributing to an improved standard of living and the broader communitys development this study focuses on the family members consistent efforts to progress aiming for personal development and a better future which significantly contribute to overall family wellbeing simultaneously embracing a purpose in life as highlighted by informant hanisah fosters a positive attitude among households and facilitates active participation in universal development the awareness of progress is crucial for a group that values trust and honesty as the absence of guidance in lifes purpose poses a threat to human civilisation furthermore a positive life direction acts as a compass for decisionmaking shaping lifestyles and work approaches according to gilles and kirby education plays a crucial role in the pursuit of knowledge fostering dedication ensuring quality and ultimately achieving the mission vision and goals of a civilisation in the context of technological advancements it becomes imperative to empower millennial women with the capabilities of technology this empowerment enables them to embrace an open mind explore new possibilities and lead a purposeful life aligned with their aspirations conclusion in conclusion this scholarly analysis has delved into the implications of technological progress on societal advancement focusing specifically on family wellbeing through the lens of millennial women the study has underlined the significant impact of technology on millennial women empowering them across multiple domains from enhancing overall health to providing financial support and planning promoting respect fostering understanding support and tolerance enabling effective communication facilitating exploration of religion and lifestyle to cultivating love happiness harmony purpose and openmindedness technology has emerged as a transformative force in shaping the lives of millennial women and contributing to their holistic wellbeing through the utilisation of digital tools and platforms millennial women have harnessed the transformative power of technology to cultivate fulfilling relationships promote emotional wellbeing explore lifes purpose and embrace a receptive mindset however it is important to acknowledge the challenges and potential drawbacks that accompany the use of technology in family life the findings emphasise the significance of a balanced approach that incorporates technology as a tool for growth and wellbeing while maintaining the core values of love support and communication within the family unit this analysis contributes to the broader understanding of the dynamic interplay between technology and family wellbeing serving as a foundation for further research and initiatives aimed at optimising the positive impact of technology on millennial womens lives and societal advancement as a whole the theoretical and contextual contributions of this research are significant in several ways firstly it expands the existing knowledge by providing a comprehensive examination of the implications of technological progress on millennial womens wellbeing within the context of family life while previous studies have explored the impact of technology on individuals and families this analysis specifically focuses on millennial women and their unique experiences shedding light on their empowerment and the transformative role of technology in their lives secondly this research highlights the multifaceted nature of technologys influence on millennial womens wellbeing it goes beyond traditional understandings of technology as simply a tool for communication or information access and explores its role in promoting various aspects of wellbeing such as physical health emotional resilience financial stability and personal growth by recognising the diverse ways in which technology affects millennial womens lives this study enriches our understanding of the complex relationship between technology and wellbeing furthermore this research contributes to the broader societal context by emphasising the importance of maintaining a balanced approach to technology use within the family unit while technology offers numerous benefits it also presents challenges and potential drawbacks that can impact family dynamics and wellbeing by highlighting the need for a mindful and balanced approach that integrates technology while upholding core family values of love support and communication this research provides practical insights for families policymakers and practitioners in navigating the digital landscape overall this research advances our understanding of the transformative power of technology in the lives of millennial women and its implications for family wellbeing by examining the theoretical and contextual aspects of this phenomenon it offers valuable insights into how technology can be harnessed to promote positive outcomes and shape societal advancement the findings of this study provide a foundation for further research and the development of interventions and policies that leverage technology for the holistic wellbeing of millennial women and their families

this scholarly analysis delves into the implications of technological progress on societal advancement specifically focusing on the wellbeing of families through the lens of millennial women the study highlights the pivotal role of technology in empowering millennial women and shaping various aspects of their lives a qualitative research study was undertaken as part of a doctoral thesis involving 31 millennial women respondents residing in malaysia the study utilised a webbased written interview methodology through google forms docs during the period of may to july 2021 amidst the backdrop of the covid19 pandemic the findings demonstrate the significant contributions of families in enhancing overall health providing financial support and planning promoting respect fostering understanding support and tolerance enabling effective communication facilitating exploration of religion and lifestyle as well as cultivating love happiness harmony purpose and openmindedness by harnessing digital tools and platforms millennial women have harnessed the transformative power of technology to nurture meaningful relationships promote emotional wellbeing explore their lifes purpose and adopt a receptive mindset however it is essential to acknowledge the challenges and potential drawbacks associated with technology usage therefore the study highlights the need for a balanced approach to integrating technology within family life wherein it serves as a tool for growth and wellbeing while upholding core values of love support and communication this analysis significantly contributes to our understanding of the dynamic relationship between technology and family wellbeing providing insights for future research and initiatives aimed at maximising the positive impact of technology on the lives of millennial women and societal advancement as a whole the study underscores the importance of adopting a holistic perspective that recognises both the benefits and limitations of technology in the context of family wellbeing ultimately paving the way for informed decisionmaking and effective utilisation of technological advancements

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introduction in europe research addressing the association between immigration background and adolescent mental health problems generally supports a risk perspective with immigrant adolescents being at a higher risk of mental health problems than their native peers 1 2 3 4 several studies highlight that socioeconomic status is important to consider in such research because immigrant adolescents relatively often grow up in low ses families eg 5 intersectionality theory 6 also highlights that the association between immigration background and adolescent mental health problems cannot be fully understood without acknowledging that adolescents belong to multiple interconnected social groups and that these social group memberships jointly shape health outcomes 78 however studies explicitly testing the role of ses and gender in the association between immigration background and adolescent mental health problems are scarce this is unfortunate as an examination of the role of ses and gender may foster our understanding of the explanatory role of ses and help us identify those immigrant electronic supplementary material the online version of this article contains supplementary material which is available to authorized users adolescents who are most at risk for mental health problems this may inform intervention and prevention efforts aimed at reducing mental health disparities between immigrant and native adolescents therefore this study investigated to what extent the association between immigration background and adolescent selfreported mental health problems can be explained by the adolescents family affluence and educational level and differs with the adolescents family affluence educational level or gender the explanatory role of family ses and adolescent educational level family ses and educational level may explain the association between immigration background and adolescent mental health problems research indicates that immigrant adolescents are less likely to grow up in affluent families 29 less likely to attend higher educational tracks compared to natives 10 and both family ses and adolescent educational level are inversely related to adolescent mental health problems 11 12 13 in europe studies mainly controlled for ses or examined the explanatory role of ses simultaneously with other family background variables studies testing the unique mediational pathways of family ses and educational level are thus rare moreover those studies that focused on the explanatory role of family ses reported inconsistent results for different types of adolescent selfreported mental health problems overall in europe family ses was found to explain the association between immigration background and internalizing problems and social problems but for externalizing problems results were inconsistent 214 for educational level even less empirical evidence is available to our knowledge only one study conducted in the netherlands examined the explanatory role of adolescent educational level and found that educational level could not explain differences in mental health problems between immigrants and natives 14 hence the explanatory role of family ses and educational level in the association between immigration background and different types of adolescent mental health problems remains poorly understood the differential impact of family ses and adolescent educational level family ses and educational level may also have a differential impact on the mental health problems of native and immigrant adolescents according to the double jeopardy hypothesis 15 the effects of having an immigration background and a low ses will strengthen each others impact immigrants encounter relatively many stressors which may deplete their coping resources and make them more vulnerable to additional stressors that are prevalent in low ses environments than natives 1617 additionally the combination of an immigration background and low ses might also result in a particularly unfavorable perceived social status 16 if such perceptions of relative deprivation are seen as being unfair they may lead to mental health problems 18 thus due to the expected combined disadvantage of having an immigration background and a low ses mental health gaps between native and immigrant adolescents may be greater for adolescents with a low than with a high ses in contrast according to the diminishing returns hypothesis 19 attaining a higher ses may confer less mental health benefits to immigrant than native adolescents immigrant adolescents with a higher ses may perceive more discrimination than immigrant adolescents with a lower ses 2021 and at the same time they may receive less social support from other ethnic group members who may not perceive them as prototypical ethnic group members anymore 2223 both processes might diminish the protective effect of a high ses for immigrant adolescents from this perspective it may be inferred that mental health gaps between native and immigrant adolescents may be greater for adolescents with a high than with a low ses studies examining the intersection of immigration background and ses are extremely scarce previous studies are almost exclusively conducted in the united states on adult samples and focused on family ses the scarcely available literature revealed inconsistent findings for different types of adolescent selfreported mental health problems for internalizing problems some studies found support for the double jeopardy hypothesis 1724 while others found support for the diminishing returns hypothesis 2125 or did not find a differential impact of ses for native and immigrant adolescents 26 the latter was also found for adolescent hyperactivityinattention problems externalizing problems and social problems 24 consequently little to nothing is known about whether the association between immigration background and mental health problems depends upon the adolescents ses the differential impact of gender the association between immigration background and mental health problems may also differ for boys and girls the intersectional invisibility hypothesis 27 argues that adolescents with multiple disadvantaged social group memberships do not fit the prototypes of the social group they belong to to illustrate the prototype of an immigrant is an immigrant boy and the prototype of a girl is a native girl this may render adolescents with multiple disadvantaged social group memberships invisible compared to their single disadvantaged peers due to this intersectional invisibility immigrant girls may experience distinct advantages and distinct disadvantages compared to their single disadvantaged peers in europe studies testing the intersection of immigration background and gender are relatively scarce and revealed inconsistent findings across different types of adolescent selfreported mental health problems some studies found that especially immigrant boys reported higher levels of internalizing problems 2829 and that immigrant girlsbut not immigrant boysreported higher levels of peer problems but lower levels of conduct problems than their native peers 30 in contrast other studies did not find gender differences in the association between immigration background and different types of adolescent selfreported mental health problems 243132 hence it remains unclear whether immigrant boys or girls are more vulnerable for different types of mental health problems than native adolescents this study given the increasingly negative sociopolitical climate towards immigrants in the netherlands 3334 it is highly relevant to examine the association between immigration background and adolescent mental health problems in the dutch context using a nationally representative sample of 1116year old native dutch and nonwestern immigrant adolescents the present study examined to what extent differences in a broad spectrum of selfreported mental health problems between immigrants and natives can be explained by the adolescents family affluence and educational level and varied with the adolescents family affluence educational level and gender since previous studies show that immigrant adolescents relatively often grow up in less affluent families and are overrepresented in lower educational tracks family affluence and adolescent educational level were expected toat least partlyexplain the higher risk for mental health problems in immigrant adolescents although the literature is inconclusive about the direction intersectionality theory 67 assumes that the association between immigration background and adolescent mental health problems differs with the adolescents family affluence educational level and gender methods measures mental health problems adolescents filled in the dutch translation of the problem scales of the strengths and difficulties questionnaire 39 consisting of four subscales measuring mental health problems each subscale includes five ordinal items with answer categories not true 0 somewhat true 1 certainly true 2 the present study used a revised version of the problem scales the sdqr 40 confirmatory factor analyses showed that the sdqr that excluded the five reverse worded items of the original selfreport sdq showed a better fit to the data than the original sdq the sdqr showed a good model fit 116867 p 0001 cfi 0939 tli 0923 rmsea 0045 while the original sdq did not demonstrate an acceptable model fit 277537 p 0001 cfi 0861 tli 0839 rmsea 0050 acceptable internal consistencies 41 were found for the conduct problems emotional symptoms and hyperactivityinattention problems subscales of the sdqr a somewhat lower internal consistency was found for the peer relationship problems subscale invariance tests indicated that the sdqr allowed for valid comparisons of mental health problems between natives and nonwestern immigrants the three family affluence levels the four educational levels and boys and girls the mplus syntax of all models testing the sdqr can be found on osfiocmga8 in the final sample the occurrence of missing values on the individual sdqr items ranged between 1 and 21 demographic variables in line with previous international studies eg 2 to measure immigration background adolescents were asked to indicate the country of birth of both their parents following previous dutch studies 24 and the definition of statistics netherlands adolescents were considered having a nonwestern immigration background if at least one of their parents was born in a nonwestern country africa latin america asia and turkey adolescents of whom both parents were born in the netherlands were considered having a native dutch background age was assessed based upon the adolescents month and year of birth and the date of the survey administration adolescents indicated their gender by responding to the question are you a boy or a girl with answer categories boy and girl adolescents also reported their educational level in the netherlands secondary education consists of four different levels low medium high prevocational education and preuniversity education the revised family affluence scale was used as a proxy for family ses fas is a valid indicator of family wealth and comprises six items on material assets in the family 42 examples of items are does your family own a car van or truck and do you have your own bedroom for yourself responses were summed into a total fas score in line with previous studies 35 adolescent were identified as having a low middle or high family affluence based upon the fas distribution in the total sample in the final sample data on the fas were missing for 106 of the native dutch and for 21 of the nonwestern immigrant adolescents analytic strategy we conducted structural equation modelling analyses in mplus version 82 43 using the weighted least squares mean and varianceadjusted estimator following recent recommendations on the sdq 44 latent variable modeling was used to measure adolescent mental health problems analyses were corrected for cluster effects of adolescents in the same school and controlled for gender and age to assure national representativeness data were weighted for educational level school grade gender and urbanicity given the large sample size a stringent significance level was applied to examine the size of the associations between immigration background and adolescent mental health problems standardized regression coefficients were interpreted using cohens d negligible small medium large 45 based on the literature five different models were specified to test our hypotheses first the direct associations between immigration background and the four latent factors representing mental health problems were examined in the total sample second a mediation model was ran to examine if family affluence and adolescent educational level can explain differences in the mental health problems of native dutch and nonwestern immigrant adolescents since children growing up in higher ses families tend to have higher educational attainments 4647 a sequential twomediator model with family affluence and adolescent educational level as ordinal mediators was examined with the wlsmv estimator a probit link function 1 was used to model the coefficients for the regression paths with the ordinal mediators as outcome variables to facilitate interpretation probit regression probabilities were calculated all other regression paths can be interpreted as linear regression coefficients 43 to compute the indirect effect of immigration background on adolescent mental health problems via family affluence andor educational level percentile bootstrapped confidence intervals were obtained partially standardized effects were used to interpret the size of indirect effects 48 finally three multigroup models were tested to examine family affluence educational level and gender differences in the association between immigration background and adolescent mental health problems the wald test was used to test whether the associations between immigration background and adolescent mental health problems differed significantly between the three family affluence levels four educational levels and boys and girls the mplus syntax of all the five models can be found on osfiocmga8 results differences between the native dutch and nonwestern immigrant adolescents table 1 shows the family affluence educational level and gender distributions for the native dutch and nonwestern immigrant adolescents there were no significant differences in the age 045 p 075 gender 597 p 002 and educational level 148 p 023 of both groups significant family affluence differences were found 4887 p 0001 with nonwestern immigrant adolescents reporting a lower family affluence than native dutch adolescents since measurement invariance was established latent means could be validly compared between the native dutch and nonwestern immigrant adolescents table 2 shows that nonwestern immigrant adolescents reported more conduct problems and peer relationship problems less hyperactivityinattention problems and equal levels of emotional symptoms compared to native dutch adolescents the explanatory role of family affluence and adolescent educational level the sequential twomediator model showed an acceptable fit to the data 139161 p 0001 cfi 0929 tli 0907 rmsea 0037 and explained a significant percentage of the variance in conduct problems emotional symptoms peer relationship problems and hyperactivityinattention problems significant indirect effects were found for immigration background on emotional symptoms peer relationship problems and hyperactivityinattention problems through family affluence no indirect effect was found for immigration background on conduct problems via family affluence being a nonwestern immigrant resulted in an increase in emotional symptoms an increase fig 1 sequential twomediator model showing the association between immigration background and adolescent mental health problems mediated by family affluence and educational level continuous lines indicate significant and dotted lines indicate nonsignificant regression coefficients nonbold numbers represent unstandardized and bold numbers represent standardized regression coefficients the rectangles represent observed variables and the ovals represent latent variables to increase readability latent factor indicators variances and residual error terms were not modelled in peer relationship problems but a decrease in hyperactivityinattention problems through changes in family affluence nonwestern immigrant adolescents were less likely to report a high family affluence than native dutch adolescents adolescents in more affluent families reported somewhat lower levels of emotional symptoms and peer relationship problems but somewhat higher levels of hyperactivityinattention problems no significant indirect effects were found for immigration background on conduct problems emotional symptoms peer relationship problems and hyperactivityinattention problems through adolescent educational level results did however indicate a significant indirect effect of immigration background on conduct problems peer relationship problems and hyperactivityinattention problems via family affluence and adolescent educational level no indirect effect was found for immigration background on emotional symptoms via family affluence and adolescent educational level being an nonwestern immigrant resulted in an increase in conduct problems peer relationship problems and hyperactivityinattention problems through changes in the adolescents family affluence and educational level compared to native dutch adolescents nonwestern immigrant adolescents were less likely to report high levels of family affluence native dutch and nonwestern immigrant adolescents in highly affluent families were more likely to attend higher educational levels adolescents attending higher educational levels reported lower levels of conduct problems peer relationship problems and hyperactivityinattention problems all indirect effects were fairly small in size furthermore comparing the model without family affluence and educational level with the mediation model including family affluence and educational level nonwestern immigrants still reported more conduct problems and peer relationship problems less hyperactivityinattention problems and equally high levels of emotional symptoms as their native dutch peers the differential impact of family affluence and adolescent educational level the association between immigration background and conduct problems 1114 p 0004 and hyperactivityinattention problems 1231 p 0002 differed across family affluence levels in contrast the associations between immigration background and emotional symptoms 237 p 031 and peer relationship problems 306 p 022 were equal across family affluence levels in families with relatively low levels of affluence nonwestern immigrant adolescents reported equal levels of conduct problems as native dutch adolescents whereas in families with middle and high levels of affluence nonwestern immigrant adolescents reported higher levels of conduct problems than native dutch adolescents family affluence did not impact the level of conduct problems of nonwestern immigrant adolescents while middle or high levels of family affluence decreased the conduct problems for native dutch adolescents compared to a low family affluence in addition in families with low and middle levels of affluence nonwestern immigrant adolescents reported lower levels of hyperactivityinattention problems than native dutch adolescents whereas in highly affluent families equal levels of hyperactivityinattention problems were reported by both groups figure 3 shows that family affluence was not related to the hyperactivityinattention problems in native dutch adolescents while for nonwestern immigrant adolescents high levels of family affluence increased their hyperactivityinattention problems compared to low and middle levels of family affluence no educational level differences were found in the association between immigration background and adolescent mental health problems the association between immigration background and conduct problems 452 p 021 emotional symptoms 044 p 093 peer relationship problems 747 p 006 and hyperactivityinattention problems 707 p 007 was similar across all four educational levels the differential impact of gender the association between immigration background and adolescent mental health problems did also not vary with the gender of the adolescent associations between immigration background and conduct problems 248 p 012 emotional symptoms 170 p 019 peer relationship problems 420 p 004 and hyperactivityinattention problems 430 p 004 were equal for boys and girls discussion it has been theorizedbut rarely explicitly examinedthat ses and gender play an important role in the association between immigration background and adolescent mental health problems interestingly the result of this study illustrate that the association between immigration background and adolescent mental health problems is largely independent of ses and gender first although nonwestern immigrant adolescents were less likely to grow up in highly affluent families this explained only a very small proportion of their higher risk for conduct problems and peer relationship problems compared to the native dutch adolescents second these differences in mental health problems were quite robust across family affluence levels educational levels and boys and girls only two interactions were revealed for native dutch adolescents higher levels of family affluence were associated with less conduct problems while there was no association between family affluence and conduct problems for nonwestern immigrants no association between family affluence and hyperactivityinattention problems was revealed for native dutch adolescents while for nonwestern immigrants a high level of family affluence was associated with more hyperactivityinattention problems studies testing the unique mediational pathways of family ses and educational level in the association between immigration background and adolescent mental health problems are rare using advanced statistical methods we were able to model the association between family affluence and adolescent educational level eg 46 and to test the explanatory role of family affluence and adolescent educational level alone and together our finding that immigration background had an indirect effect on adolescent internalizing problems and social problems but not on externalizing problems via family affluence is largely in line with previous studies 214 however the size of these indirect effects was very small which may be due to the weak association between family affluence and adolescent mental health problems in a high income country like the netherlands low levels of family affluence may still reflect relatively high material living standards therefore adolescents may have few material desires 49 which may diminish the impact of family affluence on adolescent mental health problems alternatively the dutch universal health care system that provides health care allowances for low income families may explain the weak associations found between family affluence and adolescent mental health problems in line with former results 14 adolescent educational level did not explain differences in mental health problems between nonwestern immigrant and native dutch adolescents either this is not surprising as there were no educational level differences between nonwestern immigrant and native dutch adolescents although via family affluence adolescent educational level had some explanatory power again the size of these indirect effects was fairly small thus in the netherlands other factors than ses may explain the higher risk for conduct problems and peer relationship problems of nonwestern immigrant adolescents given increasingly negative attitudes towards immigrants in europe 50 and evidence of an increasingly negative sociopolitical climate towards immigrants in the netherlands 3334 perceptions of discrimination may be a relevant factor although intersectionality theory 6 clearly emphasizes the need to study the intersections of adolescents social group memberships studies examining the role of ses and gender in the link between immigration background and adolescent mental health problems are scarce especially in europe 51 contributing to the scarce and inconsistent literature eg 17212425 our results indicated that differences in mental health problems between nonwestern immigrant and native dutch adolescents were largely comparable for different family affluence and educational levels this was also the case for gender differences which is in line with previous dutch studies 2431 two interactions between immigration background and family affluence were found however supporting the diminishing returns hypothesis only for native dutch adolescents higher levels of family affluence were associated with less conduct problems immigrants with a higher ses may be more aware of discrimination 52 and such perceptions of discrimination may diminish the protective effect of a high family ses for immigrant adolescents 21 however this effect was only found for conduct problems and not robust over the whole spectrum of adolescent mental health problems for hyperactivityinattention problems findings at first seemed counterintuitive nonwestern immigrants reported lower levels of hyperactivityinattention problems than their native peers and high levels of family affluence increased the hyperactivityinattention problems of nonwestern immigrant adolescents only studies show that higher ses immigrants have more contacts with natives than lower ses immigrants 5253 and that dutch adolescents report relatively high levels of hyperactivityinattention problems compared to their european agemates 40 due to influence processes 54 immigrant adolescents in higher ses familieswho are assumed to have more contacts with native peersmay become more similar in their behavior andor attitudes towards hyperactive and inattentive behavior to native peers and report higher levels of hyperactivityinattention problems using a nationally representative sample of dutch adolescents two indicators of ses a broad spectrum of adolescent mental health problems and a rigorous methodological design this study showed that the role of ses and gender in the association between immigration background and adolescent mental health problems is at best small still some limitations and alternative explanations of our findings should be considered first the crosssectional nature of our data does not allow for causal inferences about the explanatory role of ses our findings suggest that higher ses environments may protect against mental health problems however the opposite may also be true mental health problems may negatively impact adolescents educational careers 47 second although by establishing measurement invariance we made sure that the native dutch and nonwestern immigrant adolescents did not systematically differ in their responses on the mental health problems measures we cannot rule out that cultural differences in socialization practices may have contributed to differences in the mental health problems of the nonwestern immigrant and native dutch adolescents 55 third the hbsc study is designed to gather a nationally representative sample of dutch adolescents this is a clear advantage as our findings are generalizable to the overall population of dutch adolescents however our sample design did not allow for analyses stratified by specific immigrant group characteristics it remains to be seen whether this has sizeable consequences for our results as previous dutch studies that distinguished between immigrants with specific ethnic backgrounds found highly similar mental health differences in the different immigrant groups 5658 also in europe evidence for an immigration paradox is much less convincing than in the united states 2 59 60 61 62 notwithstanding these former findings future studies testing the generalizability of our results in a broad scale of specific immigrant groups from different countries of origin different generational statuses and with different reasons for immigration are highly relevant fourth our questionnaire was only available in the dutch language for a small group of immigrant adolescents especially those from the first generation who recently immigrated to the netherlands a language barrier may have impacted their selfreports finally in this study we only used one measure of family ses family affluence studies show that the association between family ses and adolescent mental health problems may vary with the operationalization of family ses 11 however given that especially for younger adolescents it is difficult to report on their parents occupation and educational level or family income adolescents reports of family affluence provide a particularly reliable measure of family ses 63 conclusion with nonwestern immigrant adolescents only reporting higher levels of conduct problems and peer relationship problems our study does not unequivocally support the risk perspective of immigration 1 2 3 the risk perspective of immigration may thus vary with the type of mental health problems family affluence and adolescent educational level could not explain the higher risk of conduct problems and peer relationship problems of nonwestern immigrant adolescents compared to native dutch adolescents even more these differences in mental health problems were quite robust across different family affluence levels adolescent educational levels and between boys and girls thus although it is theorized that ses and gender play an important role in the association between immigration background and adolescent mental health problems our findings indicate that in the netherlands the role of ses and gender is limited taken together our results imply that not only immigrant adolescents from low ses backgrounds but immigrants from a wide range of ses backgrounds may need prevention and intervention programs targeting their mental health specifically concerning conduct problems and peer relationship problems future studies should test whether other factorssuch as perceptions of discriminationmay account for differences in the mental health of immigrant and native adolescents moreover internationally comparative research examining the intersection of immigration background with ses and gender is needed to examine the generalizability of our findings outside the netherlands and to map mental health inequalities between immigrant and native adolescents with more precision

purpose european studies demonstrated that immigrant adolescents are at a higher risk for mental health problems than native adolescents but little is known about the role of socioeconomic status ses and gender in this association this study examined to what extent differences in the mental health problems of nonwestern immigrant and native dutch adolescents were explained by adolescents family affluence and educational level and differed with the adolescents family affluence educational level and gender methods adolescents in a dutch nationally representative sample of 1116year old native dutch n 5283 and nonwestern immigrants n 1054 reported on their family affluence own educational level conduct problems emotional symptoms peer relationship problems and hyperactivityinattention problems results nonwestern immigrant adolescents were at a higher risk for conduct problems and peer relationship problems than native dutch adolescents but family affluence and educational level explained only a very small proportion of these differences with two exceptions differences in the mental health problems of nonwestern immigrants and natives were highly comparable for different family affluence levels educational levels and for boys and girls only for natives a higher family ses was related to less conduct problems furthermore only for nonwestern immigrants a high family ses related to more hyperactivityinattention problems conclusions our findings illustrate that the association between immigration background and adolescent mental health problems is largely independent of ses and gender future studies should include other factors to facilitate our understanding of the association between immigration background and adolescent mental health problems

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introduction in the united states the chinese immigrant population is a fastgrowing minority group and bears a disproportionately high type 2 diabetes burden compared to the general adult population 12 in new york city data from an epidemiological survey of 2071 participants revealed that almost 1 out of every 2 adult chinese immigrants has t2d or impaired fasting glucose 2 this is a concerning rate given the high proportion and the continuing rapid influx of chinese immigrants over the last few decades indeed between 2000 and 2015 the new york city chinese population grew by 49 compared to 12 in the overall new york city immigrant population 3 although the poverty rate of chinese americans in new york city is comparable to that of the overall new york city population the older chinese adults who are more likely to be impacted by diabetes have a much higher poverty rate relative to the overall older adults in new york city 4 despite the high t2d burden research in this patient population is quite limited with only few diabetes intervention studies identified 5 6 7 8 in each study the interventions relied on busy health care providers or dedicated study staff to deliver them thereby limiting their sustainability and scalability each intervention required frequent travel to a central location to receive the intervention which is unlikely to be feasible in a realworld setting especially among lowincome chinese immigrants given their long work hours 910 diabetes selfmanagement education and counseling programs are evidencebased interventions that provide important knowledge skills and counseling to patients with t2d 11 chinese immigrants face numerous barriers to accessing these inperson programs 810 12 13 14 15 and these programs have proven to be effective in mostly englishspeaking populations 16 17 18 the lack of linguistically and culturally sensitive health care providers and tailored diabetes programs have been cited as the major reasons for poor diabetes outcomes in chinese americans 13 19 20 21 while over 60 of chinese immigrants report limited english proficiency in new york city 3 languageconcordant providers are also limited in number 13 19 20 21 differing cultural norms also complicate the delivery of effective diabetes care and counseling 10 13 14 15 22 these cultural and linguistic discordances between providers and patients often contribute to poor patientprovider communication inefficient diabetes education and counseling and diminished understanding and confidence in managing t2d at home 21 moreover these dsme programs are often laborintensive for providers and timeconsuming for patients 923 chinese immigrants are often engaged in lowwage jobs with long working hours limited sick leave and lack of health care insurance 4 which prevent them from participating in these inperson multiplesession programs 91022 leveraging widely used social media platforms may be a promising approach to deliver dsme to underserved chinese immigrants in a time and place that is convenient to them 2425 in a prior study we demonstrated ownership of smart devices by a majority of chinese immigrants with t2d widespread use of the free social media app wechat and a strong interest in a wechatbased dsme 26 indeed over 90 of chinese immigrants with t2d reported owning a smart device and more than 70 currently use wechat 26 given the ubiquitous nature of mobile phones a social mediabased asynchronous intervention holds strong promise to be integrated into the daily lives of chinese immigrants the goal of this pilot study was to examine the feasibility acceptability and potential efficacy of an asynchronous wechatbased dsme program in chinese immigrants with t2d methods study design the care study was a pretest and posttest singlegroup study on 30 chinese immigrants with t2d during the 12 weeks of the intervention each participant received links to 2 diabetes videos via wechat each week participants completed inperson surveys at enrollment and 3and 6month followup surveys over the telephone all participants provided written informed consent ethics approval this study was approved by the new york university grossman school of medicine institutional review board renderx wechat exclusion criteria included pregnancy breastfeeding or living in nursing homes or facilities in which participants had limited opportunity to engagement in independent decisionmaking regarding management of their t2d we chose to focus on mandarin in this study because this is among the most popular spoken languages among new york city chinese immigrants 27 recruitment screening and baseline assessment participants were recruited from a diabetes research registry that has been established from one of our prior studies 26 which aimed to examine diabetes selfmanagement behaviors in chinese immigrants with t2d in new york city study staff contacted potential participants explained the study and screened them for eligibility once eligibility was confirmed study staff scheduled a date and time to meet in person for written consent and baseline assessment intervention overview and theoretical frameworks we culturally and linguistically adapted a dsme intervention shown to be efficacious for decreasing hemoglobin a 1c levels in a highly educated nonhispanic white population in the enhance trial 28 adaptation of the enhance intervention was guided by the cultural adaptation model 29 and the ecological validity model 30 these models were chosen because they have been widely used in the literature to guide the cultural adaptation processes of evidencebased interventions the study team first reviewed the enhance intervention content to make sure it is consistent with the latest diabetes and dsme guidelines 11 and covers all of the association of diabetes care education specialists selfcare behavior topics 31 then informed by the adaptation models and our prior formative work we tailored the content based on chinese culture and norms for instance when talking about diet we used commonly consumed chinese dishes food items seasoning and cooking methods we also discussed tips to maintain healthy eating during chinese holidays when discussing medication taking we shared commonly reported barriers to medication taking in chinese immigrants and provided tailored strategies to improve medication adherence once the initial adaptations were completed the intervention content was shared with a chinese diabetes educator and a nurse for feedback on cultural relevance and content accuracy care included a 12week intervention program involving dsme videos that participants could access in a time and place convenient to them we developed 24 brief diabetes videos in mandarin chinese each week 2 video links were sent to the participants via wechat with one video focusing on diabetes education and the second one focusing on social cognitive theorybased behavioral change techniques 3031 at the end of the baseline visit participants were sent the first video and shown how to open the video by clicking the play button since all participants knew how to use wechat we did not provide any guidance around using wechat in addition to sending brief videos study staff called the study participants every 2 weeks to ask if they had questions regarding the video content and gave them an opportunity to discuss any challenges encountered in their diabetes selfmanagement efforts the phone calls typically lasted about 15 minutes measures unless specified otherwise below measurements were obtained at baseline 3 months and 6 months sociodemographic data at baseline only we collected data on age gender income education marital status employment status and english proficiency english proficiency was measured by 1 question how well do you speak english and limited english proficiency was defined as speaking english less than very well primary outcomes feasibility was measured as the percentage of those screened and eligible who enrolled in the study retention rates at 3and 6month followup and the video watch rate at the end of each video participants were asked 2 brief questions via wechat how much of the video did you watch and how helpful was the video if participants responded to these 2 questions we considered that they watched the video the number of responses was used as a proxy measure to estimate the video watch rate acceptability was measured by a 10item patient satisfaction scale used in a prior study 32 participants were provided with 9 statements regarding their experience and satisfaction to which they provided their level of agreement using a 5point likert scale participants also responded to a single 11point likertscaled item reflecting their overall satisfaction with the intervention secondary outcomes hba 1c levels baseline hba 1c was abstracted from the medical record if a result was available within 3 months prior to enrollment if a baseline hba 1c result was not available pointofcare a1cnow testing was performed followup hba 1c was obtained from the electronic record because of covid19 interruptions in the delivery of ambulatory care many participants did not seek routine care during the study midpoint and hba 1c data were not available for them however ambulatory care delivery returned to normal as the study concluded and hba 1c data were available for most participants at the 6month followup selfefficacy selfefficacy was measured with the stanford 8item selfefficacy for diabetes scale 3334 on which participants report confidence in their ability to manage various diabetes selfcare behaviors each item was rated using a 10point likert scale the final score was the mean across the 8 items with higher scores reflecting higher selfefficacy dietary intake dietary intake was measured with the 8item starting the conversation scale 35 which asks participants to report the frequency with which they consumed various foods and drinks over the past few months the final score was the sum of 8 items with a possible range of 016 lower scores reflect more healthy eating behaviors physical activity physical activity was measured with the international physical activity questionnaire 36 participants were asked whether they engaged in any vigorous moderate or mild level of physical activity over the past 7 days and the duration for each exercise intensity results were calculated in total metminutesweek 37 with higher scores reflecting a higher level of physical activity statistical analyses for primary outcomes we used descriptive statistics to summarize demographics retention rates at 3 and 6 months the video watch rate and intervention satisfaction scores for secondary outcomes we used paired 2sided t tests to identify changes over time changes in means and their 95 cis were presented we performed all data analyses using spss results characteristics of the sample population as shown in table 2 the sample consisted of 30 middleaged adults or older chinese immigrants who were primarily married women with a high school education or less an annual household income of less than us 25000 and who reported limited english proficiency feasibility and acceptability outcomes we report feasibility in the following 3 ways recruitment a total of 30 participants were recruited from january 16 to february 27 2020 prior to the onset of the covid19 pandemic in new york city we called 70 potential patients and were able to reach 45 participants of these 45 patients 38 were eligible and 30 enrolled in this study thus we needed to screen 15 patients to enroll 1 participant in the study retention rates the retention rate was 100 at 3month followup and 97 at 6month followup one participant moved back to mainland china and was lost to followup at the 6month followup video watch rate the mean video watch rate was 92 indicating that on average each video was watched by 92 of the sample the video watch rate over the 12week intervention ranged from 83 to 100 almost all reported watching the entire video when they watched a video and 86 agreed that the videos were very helpful acceptability out of a possible score of 10 with higher scores reflecting greater satisfaction the mean overall satisfaction with the intervention was 99 table 3 summarizes participants responses to each satisfaction item all participants agreed or strongly agreed that it was very easy to receive and view diabetes videos and that the videos provided very helpful information on diet and physical activity all participants strongly agreed or agreed that the diabetes videos enhanced their confidence to manage their t2d of note all strongly agreed or agreed that they preferred videobased diabetes education over inperson facetoface education in their doctors office to what extent do you agree with the following statements 0 0 0 8 22 it was easy to receive and view the wechat diabetes videos from the research team 0 0 0 3 27 i found this program to be helpful for providing me more information about healthy diet 0 0 0 2 28 i found this program to be helpful for providing me more information about physical activity 1 0 0 5 24 i found this program to be helpful at motivating me to take my diabetes medication as prescribed 20 21 i found this program to be helpful at motivating me to check my blood sugar as recommended 0 0 0 3 27 i found this program to be helpful at increasing my confidence to manage my diabetes 0 0 0 3 27 i would be willing to join similar programs in the future to help me manage my diabetes 0 0 0 7 23 i would recommend this program to my friendsfamily that have diabetes 0 0 0 6 24 i prefer to receive diabetes education via wechat than scheduling appointment and going to doctors office 2 0 1 6 secondary outcomes table 4 shows the changes in the secondary outcomes over time compared to baseline there were significant improvements at 3 months in selfefficacy while no changes were observed in dietary and physical activity behaviors between baseline and 6 months significant improvements were observed in hba 1c selfefficacy dietary behavior and physical activity discussion principal findings to the best of our knowledge this is the first study examining the feasibility and acceptability of leveraging a free social media platform to deliver culturally and linguistically tailored asynchronous dsme to underserved chinese immigrants with t2d the results of this study demonstrated high feasibility and acceptability of this intervention the retention rate was comparable to or better than that previously reported in inperson diabetes interventions in chinese immigrants 8938 the video watch rate was high over the 12week intervention with an adherence rate higher than most inperson dsme interventions in chinese immigrants 68938 for example in a study of 145 chinese immigrants with t2d chesla and colleagues 8 examined the effect of a 6session intervention program and found that the cumulative percentages of participants who attended 4 5 or 6 sessions were 92 79 and 58 respectively similarly in another inperson diabetes prevention program in chinese immigrants the average session attendance was 77 38 several factors may explain the higher engagement observed in this study including culturally and linguistically tailored intervention content bilingual study staff and remote delivery of the intervention via a commonly used social media app to chinese immigrants which allows participants to access the intervention videos at a time and place convenient to them in addition the study staff called participants every 2 weeks to check whether they had any questions with regard to the video content which may help build a trusting relationship with participants and thus enhance retention and engagement the intervention in this study shows promise for improving glycemic control and key diabetes psychosocial and behavioral outcomes the reduction in hba 1c levels was both statistically and clinically significant with an effect size similar to inperson but more laborintensive dsme programs 39 we also found that participants reported higher selfefficacy for managing t2d and better adherence to diet and physical activity which have been considered as critical factors in improving glycemic control and diabetes outcomes 1140 it is possible that the effect of our intervention was mediated by improvements in selfefficacy and adherence to selfmanagement behaviors the small sample size of this study precluded the possibility of mediation analyses future large randomized controlled trials may consider exploring the mechanism of this social mediabased dsme intervention the literature regarding mobile healthbased interventions has been rapidly growing over the past few decades however most published studies have focused on developing and designing sophisticated applications or technologies to serve welleducated englishspeaking populations 41 use of mobile technologies to deliver health education to underserved populations particularly marginalized lowincome immigrants with limited english proficiency is largely untested 41 42 43 our data suggest that leveraging a communication app widely used by an underserved immigrant community is feasible for delivering asynchronous dsme among chinese immigrants the intervention is acceptable and promising to improve diabetes outcomes and related health behaviors among lowincome chinese immigrants the data in this study need to be interpreted cautiously and additional research will be required to confirm the results given the small sample and pretestposttest study design in addition the video watch rate and program satisfaction were measured by selfreported questions that could reflect response bias nonetheless this study is the first to examine the use of a free social media platform to increase access to culturally tailored dsme among underserved chinese immigrants future largescale randomized controlled trials are needed to explore whether this approach can be used for other chronic disease management interventions or in other highrisk immigrant populations in the united states use of a free widely used communication platform enhances future scalability and minimizes potential digital literacy concerns conclusion underserved racial and ethnic minority and immigrant populations bear disproportionately high burden of t2d and face numerous barriers to accessing culturally appropriate dsme in this study we demonstrate the feasibility acceptability and potential efficacy of an asynchronous intervention that employs a free social media platform to deliver culturally and linguistically tailored dsme videos to underserved lowincome chinese immigrants these findings add to the scarce literature on the use of mobile health interventions in underserved populations future studies are required to confirm the efficacy of the intervention in a randomized controlled trial conflicts of interest none declared abbreviations

background chinese immigrants bear a high diabetes burden and face significant barriers to accessing diabetes selfmanagement education dsme and counseling programsthe goal of this study was to examine the feasibility and acceptability and to pilot test the potential efficacy of a social mediabased dsme intervention among lowincome chinese immigrants with type 2 diabetes t2d in new york citythis was a single group pretest and posttest study in 30 chinese immigrants with t2d the intervention included 24 culturally and linguistically tailored dsme videos focusing on diabetes education and behavioral counseling techniques over 12 weeks participants received 2 brief videos each week via wechat a free social media app popular among chinese immigrants primary outcomes included the feasibility and acceptability of the intervention feasibility was evaluated by recruitment processes retention rates and the video watch rate acceptability was assessed via a satisfaction survey at 3 months secondary outcomes that is hemoglobin a 1c hba 1c selfefficacy dietary intake and physical activity were measured at baseline 3 months and 6 months descriptive statistics and paired 2sided t tests were used to summarize the baseline characteristics and changes before and after the interventionthe sample population n30 consisted of mostly females 2130 70 who were married 1930 63 with limited english proficiency 3030 100 and the mean age was 61 sd 7 years most reported an annual household income of us 25000 2430 80 and a high school education or less 1930 63 thirty participants were recruited within 2 months january and february 2020 and 97 2930 of the participants were retained at 6 months a video watch rate of 92 2830 was achieved the mean baseline hba 1c level was 73 sd 13 and this level declined by 05 95 ci 08 to 02 p003 at 6 months the mean satisfaction score was 99 sd 06 out of 10 indicating a high level of satisfaction with the program all strongly agreed or agreed that they preferred this videobased dsme over facetoface visits compared to baseline there were significant improvements in selfefficacy dietary and physical activity behaviors at 6 months

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background active transport is a type of physical activity that offers health benefits to adolescents such as higher levels of daily physical activity 1 lower odds of being overweight or obese 23 higher levels of cardiovascular fitness 45 and a better cognitive performance 6 an increase in active transport might also reduce traffic congestion and co 2 emissions 7 since a steep decline in activity levels and in active transport occurs in adolescence 189 it could be important to focus on active transport to increase the daily physical activity in older adolescents 10 especially since belgian adolescents are allowed to drive a moped from the age of 16 and a car from the age of 18 older adolescents also become more independent they perceive less parental control and more peer pressure 11 and they are allowed to purchase and consume alcohol from the age of 16 furthermore as physical activity tracks stronger from late adolescence to adulthood than from early adolescence to adulthood 1213 increasing walking or cycling for transport in older adolescents may be particularly important because this transport choice may persist into adulthood designing effective interventions to promote active transport in older adolescents requires a comprehensive understanding of the correlates of active transport 14 ecological models state that physical activity is influenced by an interplay between psychosocial sociodemographic and physical environmental factors and each of these factors needs attention in research 1516 to date most research investigating correlates of active transport in adolescents has only focused on young adolescents 1718 and on active transport tofrom school 15 17 18 19 20 21 however correlates of active transport are likely to differ from young adolescence to older adolescence furthermore as the most consistent correlate of active commuting is distance to school 19202223 it might also be important to promote active transport to other destinations within older adolescents neighborhoods given that they may not live within easy walking or cycling distance from school the criterion distance for active transport to school in older adolescents in belgium could be set at eight kilometers for cycling and two kilometers for walking 20 but even within the distance of eight kilometers approximately 40 of adolescents use passive transport to go to school as shown in a belgian and a uk study 2023 a review of qualitative studies on the views of children young people and parents about walking and cycling 24 also described a culture of car use they found that young people perceive active transport as less safe pleasant and convenient than car travel therefore it might be important to conduct an indepth investigation of the factors influencing transport mode choice for short distances in older adolescents to our knowledge no studies on active transport in adolescents to destinations other than school have been conducted not only knowledge about correlates of active transport is important it is also necessary to be aware of the barriers and facilitators of other modes of transportation knowing why older adolescents choose to drive a moped or ask their parents for a ride might help in explaining participation in active transport there is no information on which factors push older adolescents into the use of mopeds for travelling short distances once they reach the age they are allowed to drive these motorized vehicles since transport habit is a strong correlate of transport mode choice 25 it is important to promote active transport before the use of motorized transport modes for travelling short distances becomes a habit furthermore public transport might be a good alternative for active transport as the additional minutes of walking before and after use of public transport may help to increase activity levels and reduce health risks 2627 to date not much is known about the factors influencing transport choice for short distance travel to various destinations in older adolescents there is a need for qualitative studies to explore this research area as qualitative research methods offer a broad and indepth insight into the individuals experiences and perceptions 28 focus groups provide the possibility to learn and get a broad range of information about topics that are poorly understood especially in particular segments of the population such as older adolescents 29 interactive group discussions stimulate a process of sharing and comparing and different points of view are revealed 30 therefore a qualitative study was conducted in order to explore the factors influencing the choice of transport mode for short distance travel to various destinations in older adolescents methods sampling focus group participants were recruited in march 2012 from a secondary school in antwerp and consisted of 32 volunteers from the two final years in general technical occupational and artistic studies these are the four main study disciplines available for secondary school students in belgium in which general studies prepare for higher education technical studies have a more technical and practical approach occupational studies are very job specific and artistic studies combine general education and art practice because distance is a very dominant barrier for active transport the study was conducted in the city of antwerp with 506225 inhabitants and a population density of 2478 inhabitantskm 2 antwerp has a single condensed urbanized builtup area with plenty of destinations for short distance transportation 31 the study protocol was approved by the ethics committee of the university hospital of the vrije universiteit brussel all participants agreed to participate in the study via informed consent and gave permission for their quotes to be used in research publications research protocol and measures the protocol consisted of two parts a brief and basic questionnaire followed by focus group discussions first the participants completed a questionnaire collecting sociodemographic data data about transport modes transportation preferences distance to school and driver license possession physical activity was also assessed with one selfreport question such single questions have shown to have a good validity in studies among adults where physical activity is not the primary focus and more detailed measures are not feasible 32 focus groups were held until saturation was reached since a sample size cannot be predetermined given the need for a thorough exploration of an as yet unknown behavior 33 in total five focus groups were held with a range of five to eight participants per group all focus groups were conducted in dutch and lasted approximately 50 minutes a focus group protocol and a semistructured discussion guide were developed in consultation with all coauthors and were consistent with recommended focus group methodology 34 the guide consisted of several questions including an opening question an introduction question a transition question five key questions and an ending question most of the discussion time was spent on the key questions asking which factors determine adolescents transport mode choice to school and to other nearby destinations whether and why their transport mode choice changed in the last three years and the advantages and disadvantages of the different types of transportation for short distance travel the questions aimed to uncover facilitators and barriers of all types of transportation the moderator used the focus group guide to lead the discussions allowing ample time for participants to respond to questions and comments from other participants in addition designated observers were present to take notes and to make sure the moderator did not overlook any participants trying to add comments the students were offered an incentive for their participation in the focus group discussions with permission of the participants all conversations were audiotaped and filmed to inform the transcription of focus group interviews data analysis data obtained by the questionnaire were entered into an spssfile to calculate descriptive statistics data from the audio tapes were transcribed verbatim transcripts of the focus group conversations were entered into nvivo 9 qualitative software to analyze the data based on grounded theory grounded theory is a method of analyzing qualitative data which is grounded in the data without preconceived theories and is characterized by intensively analyzing data often sentence by sentence or phrase by phrase 35 codes were developed by ds throughout the focus groups and during the transcription of the audio recordings according to the responses and the themes which arose frequently and were relevant to the aim of the study ds assigned segments of the transcripts to the codes codes were then grouped into broader categories the codes to be used and the assignment of segments to codes were validated by two other researchers doubts or disagreements were discussed until consensus was reached as suggested by sandelowski 36 and previously used by van cauwenberg et al 37 the qualitative data are reinforced by quantitative counts of the participants discussing certain factors influencing their choice of transportation thus when a factor was discussed by less than 25 we called it few for between 25 and 50 we called it some for between 50 and 75 we called it a lot of and for more than 75 of the participants we called it almost all in the results description results descriptives descriptive statistics are described in table 2 there were slightly more boys attending the focus groups than girls adolescents reported less cycling to school compared to other destinations and a greater use of carmoped and public transport to school than to other destinations no adolescents in this study owned a car driver license content analysis qualitative data analysis revealed three main themes with several factors that affected choice of transport mode in older adolescents personal factors social factors and physical environmental factors weather built environment perceived safety and ecology personal factors autonomy a lot of participants said that they do not like to be dependent on something or someone when it comes to transportation this was considered an advantage of active transport cycling to destinations provides the adolescents with a great deal of independence because it is very reliable they can go and leave when they want even in the evening or at night it provides them with a direct route to their destination and they are independent from their parents driving them only walking offers an even greater amount of freedom as mentioned by few participants because then you do not have to think about the keys or lights for the bicycle but this was only considered practical for very short distances on the other hand public transport has a lot of disadvantages that impacted negatively on autonomy such as long waiting times delays traffic jams limited availability in the evening and only access to a limited amount of destinations for example one boy said if you go somewhere by bicycle you have all the freedom if you want to change direction on the go or something like cost was also considered a barrier for using public transport by some participants they said that it is rather expensive when you have to buy a ticket every time when their parents would pay for the ticket or when they had a subscription they would take public transport more easily this was illustrated by a male participant saying i dont have a subscription so if i want to take the bus i have to consider whether i still have any money otherwise ill have to walk or cycle health few participants mentioned physical health as a factor in the choice of transport mode some of them thought it is just an extra benefit that riding a bicycle is good for their physical fitness and others even doubted whether cycling in a city is healthy they suggested that the car exhausts have a rather negative influence on their health a female participant mentioned my mom says i have to cycle because its healthy but i dont think it is very healthy all those car exhaust youre inhaling counter the health benefits of cycling a distance social factors social influence it was mentioned by a lot of adolescents that friends parents and partners have an influence on their transport mode that influence can be positive or negative for instance a lot of adolescents like to cycle to destinations with one or more friends they would also cycle longer distances when they are not alone but if the friends in their environment regularly take public transport have a drivers or a moped license they will also join in these motorized transport modes this was illustrated by a male participant who said if i go out with friends and they would go by car it is logical that i will also ride along so you do not have to go alone it depends on what they choose those friends and then you automatically go along adolescents with a moped mentioned that the social aspect was one of the most important factors in driving a moped when meeting friends at the destination a few adolescents mentioned they do not like to arrive sweaty and redfaced so they might consider not taking a bicycle for this reason few participants said that their parents encouraged them to use active transport by setting example or by not allowing a ride with the car however few others also said that their parents like to drive them to destinations by car when the weather is bad or because they do not want to use active transport themselves adolescents with partners with a moped or driver license also mentioned often getting a ride from their partner physical environmental factors travel time a lot of participants stated that to travel short distances they usually choose the fastest transport mode in the city this is mostly the bicycle for example one female participant said yes if you go by bicycle you are always faster than going by bus because by bicycle you can choose your own pace and you dont have to wait as long as for public transport adolescents with a moped license also mentioned travel time as a facilitator of driving a moped with a moped they have the advantages of cycling but travel time is even shorter when they have sufficient time some adolescents might choose public transport or walking accessibility access to transport modes access to transport modes was discussed by some participants none of the adolescents had a drivers license yet so access to a car was limited to being a passenger some of them said that sometimes they could ride as a passenger with parents or friends and few also admitted that if they would have their drivers license and a car they would probably often go by car adolescents who regularly took public transport said that this was because public transport stops were near to their home for example one boy said i do not live far from the transit zone for all the busses and that is an advantage for me i have all the options i can take any bus to school or back home public transport is always the first choice for me if a public transport stop is not nearby the adolescents mostly cycle or walk to their destination almost all adolescents mentioned having a bicycle except for few whose bicycle got stolen only few adolescents mentioned having a moped access to facilities some participants mentioned that it is important to have access to good bicycle storage or a bicycle parking at their destination if not they would consider taking an alternative transport mode because they do not want their bicycle or moped to get stolen some adolescents considered bicycle sharing programs as very practical transport modes one participant indicated i like the bicycles that are spread all over the city and that you can rent for a very cheap price because there are so many of those bikestations in the city it gives an easy access to transportation when their own bicycle is not available or broken and there is no good access to public transport some adolescents mentioned using these shared bicycles weather the weather is an important factor in choosing a transport mode according to a lot of adolescents in rain snow or ice they like to take motorized transportation such as public transport or a ride with a car some of them also admitted that in bad weather they would probably go by car once they have their driver license although few of them stated that with the appropriate rain gear they would still take their bicycle for example one female participant said if its raining a little bit it is not a problem to cycle but if its pouring rain i would ask my mom to give me a ride built environment some participants mentioned the built environment as a factor in choosing between transport modes a good cycling path and roads that are not too busy are important for choosing to cycle a female participant indicated for instance if the road is really bad with holes and bumps and all then you have to make a detour and then you have to cycle for 15 minutes more then i would ask my parents to drive me when it comes to cars few said that if they had a driver license they would not take their car to certain destinations in the city because of the lack of parking lots and the traffic jams safety although a lot of participants said something about safety it did not seem to be a very important factor of transport mode choice they reported that it is mostly a matter of being careful yourself and that they would not change their transport mode for safety reasons traffic safety some of the adolescents mentioned traffic safety as a factor influencing their transport mode choice they said that by riding a bicycle they are vulnerable road users busy traffic and a lack of good and clear cycling paths make cycling more dangerous but according to the adolescents these aspects do not make them change transport mode on the other hand snow and ice on cycling paths does make some adolescents switch to motorized transportation although none of them had a drivers license for motorcycles they were considered very dangerous by the participants for example one girl said my mother has a motorcycle and she already fell a couple of times and my stepfather also has a motorcycle and he was even hospitalized once so i do not want to do that i do not want a motorcycle no way safety from crime personal safety was only brought up by a few adolescents they mentioned that they did not want to cycle to certain places because they are afraid their bicycle might get stolen ecology only few participants said something about ecological aspects they thought that it is a disadvantage that a car is bad for the environment and an advantage that cycling and walking is good for the environment but that this would not be a decisive factor in transport mode choice for instance a female participant said its not because you suddenly start cycling that the environment is going to get better theres no point in cycling for that reason discussion the current study used focus groups to investigate the influencing factors of transport mode choice for short distance travel to various destinations in older adolescents the findings show that choosing between transport modes is not influenced by one factor but by a combination of factors which influence each other for older adolescents the interplay between short travel time high autonomy social factors low costs good access to transport modes and facilities and good weather were the most important factors in favor for choosing active transport over other transport forms other wellknown factors such as safety ecology and health do not seem to have a big influence these factors may not be as important focus points when making policy to promote active transport in older adolescents in this study cycling was the most popular transport mode throughout the focus group conversations it became clear that a bicycle offers several benefits that are particularly salient for older adolescents first of all cycling is a fast way of travelling in urban areas secondly it offers them autonomy this aspect is not yet discussed in research most likely because in previous research focus has been on younger adolescents 1718 and they receive lesser freedom from their parents to travel independently in comparison to older adolescents for older adolescents it is important that their transport modes are flexible with a bicycle it is possible to go to all destinations at all times whenever they want and at their own pace thirdly the social aspect of cycling is very appealing older adolescents like cycling together with friends and might also cycle longer distances when they are not alone this is in line with previous research in youth older adolescents and adults where social support and modeling was positively associated with cycling for transport 20 38 39 40 the popularity of cycling could be explained by the fact that this study was conducted in flanders belgium because of geographical and climatological advantages flanders has a real cycling mentality with 347 of the households owning 3 or more bicycles and 262 of the population cycling at least once a week for transportation 41 previous research conducted in flanders also found a high percentage of cycling in older adolescents 20 this is also reflected in bicycle sharing programs which is relatively new but very popular in belgium the adolescents find these bicycles cheap practical and very accessible although bicycle sharing offers several social and environmental benefits and has become increasingly popular across the globe 42 research concerning this type of transport is still scarce the main barrier for cycling in this study is the weather this is in line with the study of yang et al 43 who stated that the use of active transport in adolescents exhibited clear seasonal patterns high during summer months and low during winter months winters et al 44 also found that fewer people cycled in cities with more days of precipitation or freezing temperatures although weather is a factor that cannot be influenced the consequences of bad weather are changeable for instance in winter snow or ice on walking and cycling paths should be removed making it safe and more pleasant to use active transport safety which is regularly stated to be a barrier of active transport in previous research in children and young adults 24 was less important for older adolescents choice of transport in the present study this is in line with a study among adolescents of forman et al 45 and could be explained by the agegroup as older adolescents get to make more travel decisions themselves and are less influenced by parental concerns about safety issues than younger adolescents 46 a second explanation could be the safety in numbers phenomenon 47 which says that the average cyclist is safer in communities where there is more bicycling because motorists adjust their behavior in the expectation of encountering cyclists on the other hand concerns about bicycle theft were a barrier for cycling in this study as suggested by the adolescents themselves more bicycle storage and safe bicycle parking would be required to promoting active transport research on bicycle theft and bicycle storage is scarce although a study of titze et al 48 found that safety from bicycle theft was positively associated with regular cycling in a population of university students walking as a transport mode has several advantages in line with those from cycling but as the older adolescents want their travel time to be as short as possible walking is probably more suitable as transport mode for people in other age categories such as older adults 49 although in a study on active transport and physical activity in adolescents in ten european countries commuting by bicycle was reported less frequently than walking 1 in this study only a few adolescents drove mopeds this is in line with the results from the travel behavior research flanders who found that only 227 of older adolescents in flanders use a moped as their main transport mode 41 the main barrier for not driving a moped is the financial aspect facilitators for driving mopeds were the short travel time and the social aspect to the best of our knowledge no previous research on barriers or facilitators of moped use in older adolescents has been conducted results showed that public transport is not very popular in older adolescents the public transport system in flanders has several weaknesses that are especially barriers for older adolescents for instance the limited evening night and weekend schedules make it difficult to participate in social events and nightlife activities using public transport this finding is consistent with the results of calafat et al 50 who found that the provision of late night public transport is essential for young individuals in the prevention of traffic risk behaviors during nightlife the frequent delays and long waiting times between vehicles are also negative since a short travel time is important for older adolescents furthermore older adolescents find public transport rather expensive indeed a study of jones et al 51 where bus fare exemptions for adolescents in london have been studied showed that eliminating the cost of getting on a bus might positively affect wellbeing in general it broadens the capacity for all young people to travel independently of adult supervision and opens up a network of public mobile places in which young people can actively maintain their community of friends in a relatively accessible setting 51 it might be interesting to investigate how the public transport system can be improved to meet the needs of young people belgian adolescents are allowed to drive a car and a motorcycle from the age of 18 most adolescents in this study were planning on doing this and were looking forward to driving a car a car would offer an even greater amount of autonomy it would also reduce travel time and eliminate the barrier of weather a recent study from line et al 52 confirms these findings as they found that young people often have a strong preference for the car due to the speed freedom and positive image they believe it would provide them driving a motorcycle did not seem to be something adolescents of the present study want to do in the near future the possible safety issues are a barrier to this transport mode previous research did indeed confirm that in belgium young adults are compared to other age groups most likely to be involved in a causality accident with a motorcycle 53 according to rutter and quine 54 a particular pattern of behavior notably a willingness to break the law and violate the rules of safe riding is associated with motorcycle accidents in youth there are several limitations in the present study first 75 of the participants lived in or at the edge of the city so results may not be generalizable to rural areas second active transport was rather high in this group of participants making it harder to gather why some older adolescents do not use active transport for short distance travelling third results might be different in other countries since belgium and specifically flanders has good geographical and climatological conditions for cycling and a real cycling mentality fourth although the interactive aspect of the focus groups is a benefit it might also cause a social desirability bias but as this is the first study investigating transport mode choice for short distance travel to various destinations in older adolescents using qualitative data results are unique resulting in detailed and indepth information conclusions in summary for older adolescents choosing between transport modes for travelling short distances to various destinations is not influenced by one factor but by a combination of factors which influence each other since driving a car is not yet an option cycling has the most advantages for older adolescents it is a fast transport mode it offers a lot of freedom to go to many places at all times and they can easily cycle together with friends no bicycle storage at the destination and snow and ice on cycling paths are barriers for cycling on the other hand walking is only practical for very short distances driving a moped also offers advantages such as a fast travel time autonomy and the social aspect but the financial costs are a serious barrier furthermore public transport has a lot of disadvantages such as a long travel time and little freedom and flexibility health benefits and the ecological aspect are no important factors in choosing between transport modes for older adolescents if quantitative studies in a representative sample of older adolescents can confirm these findings researchers should take these factors into account when developing interventions to enhance active transport over short distances to various destinations in older adolescents competing interests the authors declare that they have no competing interests authors contributions ds pc idb and bd developed the study design ds conducted the data collection ds performed the data analysis ds drafted the manuscript and all other authors critically reviewed and revised versions of the manuscript all authors read and approved the final manuscript

background since a decline in activity levels occurs in adolescence active transport could be important to increase daily physical activity in older adolescents 1718 years to promote active transport it is necessary to be aware of the barriers and facilitators of this type of transport but also of other transport modes this study sought to uncover the factors influencing the choice of transport mode for short distance travel to various destinations in older adolescents using focus groups methods thirtytwo focus group volunteers mean age of 17 ± 12 years were recruited from the two final years of the secondary school in antwerp belgium five focus groups were conducted five to eight participantsgroup content analysis was performed using nvivo 9 software qsr international grounded theory was used to derive categories and subcategories results data were categorized in three main themes with several subcategories personal factors high autonomy low costs and health social factors good social support and physical environmental factors short travel time good access to transport modes and to facilities good weather an adapted built environment perceived safety and ecology conclusions for older adolescents the interplay between short travel time high autonomy good social support low costs good access to transport modes and facilities and good weather was important for choosing active transport over other transport forms for travelling short distances to various destinations other wellknown factors such as safety ecology and health seemed not to have a big influence on their transport mode choice

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background early sexual initiation refers to engaging in sexual activity at a young age typically before the age of 18 1 early initiation of sexual intercourse is a risk factor for teenage pregnancy and contracting hiv and other sexually transmitted infections 2 3 4 individuals who engage in sexual activity at a young age tend to have an increased likelihood of engaging in highrisk sexual behaviors such as having multiple partners and a reduced likelihood of using condoms delaying sexual debut is the corner of hivsti prevention among young people 5 globally the high prevalence of teenage pregnancies among young age girls in particular is a major public health concern for the majority of parents guardians and dutybearers 67 youth in subsaharan africa have been reported to engage in high rates of premarital sexual activity as several studies have found 8 in ethiopia 29 of youth had their first sexual intercourse before the age of 15 years old and 62 of them had their first sexual intercourse before the age of 18 years old the median age at first sexual intercourse for women is 166 9 according to the 2016 edhs the median age at first sexual intercourse is 05 years earlier than the median age at first marriage for women and 25 years earlier for men this indicates that both women and men engage in sex before marriage 10 the timing of initial sexual activity is a matter of public health concern 11 the occurrence of giving birth at a young age has been associated with increased rates of maternal and child illness and death limited educational options reduced family income in the future and larger family sizes which may ultimately result in higher population growth 1213 in addition it consequences higher rates of unintended pregnancy abortion hivaids and other sexually transmitted infections among youths 14 as indicated by various studies being female 15 16 17 18 19 20 residence 21 22 23 religion 6 21 22 23 24 25 self and parental education 1922 socioeconomic status 61922 alcohol use 1619 21 22 khat chewing 162224 cigarette smoking 20 viewing pornographic films at age 18 years 161724 visiting night or day party 17 classmate friendpeer pressure 18192324 poor family controls 6162025 positive attitudes regarding condom efficacy 21 poor knowledge of hivaids prevention 22 and more positive attitudes to family planning use 21 were the factors associated with early sexual initiation so it is crucial for a need to understand and assess the factors that are associated with early sexual initiation even though many studies have been conducted in ethiopia the result is inconsistent between studies in the study area the pooled prevalence and associated factors of early initiation of sexual intercourse among youth were not done before assessing the pooled result will help to inspire governmental commitments and increase the mobilization of financial resources to enhance the implementation of evidencebased interventions to culminate the effect of early initiation of sexual intercourse among youth in particular and the nation in general therefore this study aimed to determine the pooled prevalence and associated factors of early initiation of sexual intercourse among youth in ethiopia methods study design and search strategy the protocol of this systematic review and metaanalysis had been developed based on the preferred reporting items for systematic reviews and metaanalyses protocol 26 a systematic review and metaanalysis of published and unpublished studies were performed to assess the pooled prevalence and associated factors of early initiation of sexual intercourse among youth in ethiopia electronic databases such as pubmed cochrane library hinari and google scholar were used the following key terms were used to search studies prevalence magnitude proportion early initiation of sexual intercourse sexual intercourse risky sexual behavior sexual behavior sexual desired condom utilization and hiv test factors determinants predictors factors associated associated factors risk factors youth college students high school students undergraduate students ethiopia by a combination of boolean operators and or or as applicable and the search was made by three authors independently inclusion and exclusion criteria this review includes all accessible studies done from 2008 to 2022 all published and unpublished studies conducted on the prevalence and associated factors of early initiation of sexual intercourse among youth in ethiopia were incorporated in the review all observational studies with english language publications that measured recommended that targeted interventions be put in place to address the high prevalence of early initiation of sexual intercourse among youth in ethiopia these interventions should focus on addressing the associated factors such as poor knowledge of hivaids prevention alcohol use khat chewing viewing pornographic films cigarette smoking and poor family controls it is important that these interventions are gendersensitive and take into consideration the unique challenges faced by females in accessing sexual and reproductive health services keywords early initiation of sexual intercourse youth systematic review metaanalysis ethiopia the prevalence of early initiation of sexual intercourse among youth in ethiopia were considered in this review however irretrievable from the internet or those who have not received an email reply from the corresponding authors and studies with poor methodological quality were omitted from the review study selection quality appraisal and data extraction all articles explored from selected databases were exported to endnote x20 and duplicate files were dropped three investigators screened the leftover articles and abstracts for inclusion in the fulltext appraisal the difference between reviewers was managed through discussion and disagreement was handled by the third party the joanna briggs institute critical appraisal checklist for the prevalence study was used to evaluate the quality of articles that fulfilled the inclusion criteria 27 two reviewers independently assessed articles before inclusion in the review articles with quality scores of fifty and above were considered in the final review microsoft excel 2013 sheet was used for data extraction the information on the authors name year of study study design response rate sample size study quality score and prevalence were contained in the data extraction tool statistical methods and analysis data were analyzed using stata 17 software the pooled odds ratio with 95 ci was determined to estimate the determinants of early initiation of sexual intercourse among youth pooled analysis was conducted using the inversevariance fixedeffects model since there was no evidence of detected heterogeneity the existence of heterogeneity among studies was examined by the forest plot cochranes q test as well as the i² heterogeneity test the cochrane q statistic was considered significant if the pvalue is 010 while the i 2 statistics of at least 50 were considered to be significant 28 funnel plots analysis egger weighted regression and begg rank correlation tests were done to detect publication bias 2729 moreover duval and tweedies trim and fill method was used to estimate the number of missing studies from the metaanalysis 30 registration and reporting this systematic review and metaanalysis were registered in the prospero with a crd number of 42023413767 results study selection this review included published and unpublished studies on the prevalence and associated factors of early initiation of sexual intercourse among youth in ethiopia a total of 21 records were identified through electronic database searching five duplicated records were removed and the remaining articles were excluded using their titles and abstracts ten fulltext articles were evaluated for eligibility characteristics of included studies all studies included in this systematic review and metaanalysis were crosssectional the sample size of the studies ranged from 326 to 1294 overall this systematic review and metaanalysis included a total of 6355 study participants the studies were carried out from 2008 to 2022 in different parts of ethiopia prevalence of early initiation of sexual intercourse pooled analysis was conducted using the inversevariance fixedeffects model since there was no evidence of detected heterogeneity where i 2 00 p 0001 cochrans q statistic k 9 pvalue 0661 and forest plot the pooled prevalence of early initiation of sexual intercourse among youth in ethiopia was 360 however due to the presence of publication bias trim and fill method of analysis was done to correct for funnel plot asymmetry and adjust the final pooled estimate therefore the final adjusted pooled prevalence of early initiation of sexual intercourse was 247 the funnel plot also revealed an asymmetrical appearance furthermore eggers regression asymmetry test indicated significant publication bias pvalue 00447 and begg rank correlation tests pvalue 00491 pooled associated factors of early initiation of sexual intercourse this metaanalysis indicated that the sex of the youth knowledge of hivaids prevention alcohol use khat chewing view of pornographic films cigarette smoking and poor family controls were the pooled factors of early initiation of sexual intercourse among youth in ethiopia being female is three times more likely to practice early initiation of sexual intercourse as compared to males those who have poor knowledge of hivaids prevention 35 times more likely to have early initiation of sexual intercourse than good knowledge those who drank alcohol were two times more likely to have early initiation of sexual intercourse compared to those who did not use alcohol khat chewer was three times more likely to have early initiation of sexual intercourse as compared to not chewer the odds of early initiation of sexual intercourse for youth who were viewed pornographic films about 4 times higher than discussion early initiation of sexual intercourse is a risk factor for teenage pregnancy and contracting hiv and other sexually transmitted infections this study aimed to estimate the pooled prevalence and associated factors of early initiation of sexual intercourse among youth in ethiopia based on the findings the pooled prevalence of early initiation of sexual intercourse among youth in ethiopia was 247 this finding is in line with a study done on teenagers in the united states 31 china 32 busan korea 33 subsaharan africa 34 these findings could suggest that the issue of early sexual initiation among youth is a common public health concern among young people worldwide regardless of differences in sociocultural settings but it is lower than the study done in brazil 35 the possible discrepancy might be due to the reason for early sexual initiation in the study area being the sociocultural activities that are highly valued and practiced among youths in that specific area which may not be the case in the former studies with low prevalence in this study female is more likely to practice early initiation of sexual intercourse as compared to male this study was consistent with studies conducted in different areas 203637 it is because of cultural constraints that females are often given less power to resist the pressure associated with sexual relationships although females mature earlier than males physiologically physical maturation alone may not be accountable for early sexual activities the sociocultural beliefs and attitudes of society towards early sex along with the limited decisionmaking power of young girls maybe the reasons for early sexual initiation in the study area and beyond it is against the study conducted in busan korea 33 this may be due to cultural norms that encourage and approve of the sexual experimentation of males and the value given to virginity for females the current finding revealed that those smokers and alcohol drinkers commence sex at an earlier age and the result was consistent with other studies in busan korea 33 and south africa 38 this study was also in line with a study done in ghana 39 this might be due to the effect of substances which alters the healthy thinking ability of the youth and results in unplanned and unsafe sex youths who chewed khat were also found to be more likely to initiate sexual intercourse earlier than their counterparts this finding was consistent with previous studies 1622 these circumstances may arise because beer houses generally offer chances to find casual partners additionally youths are more likely to engage in unprotected sex after chewing chat because it diminishes their selfcontrol and sexual negotiation skills 40 another possible explanation for this implication could be due to a change of track of mind tempted by chat chewing which stirred them to have early sexual initiation 41 youths who have poor knowledge of hivaids prevention are more likely to practice early initiation of sexual intercourse than good knowledge this is similar to the study findings from nigeria 42 the possible reason for this might be that knowledge about hiv transmission will enable them to avoid early sexual intercourse because they know the consequences of early initiation of sexual intercourse which includes hivaids in the current study the odds of early initiation of sexual intercourse for youth who were viewed pornographic films higher than for those who did not view pornographic films this finding was in line with other studies conducted 1743 this could be because pornographic materials can stimulate psychological and mental sexual desire and empress to experiment with what has been observed the impulsive nature of pornographic materials leads to erotic sexual stimulation or early sexual practice 4445 youth who had poor parental monitoring were more likely to start sexual activity early than those who had good parental monitoring this is consistent with studies done in kenya 46 it is supported by these discoveries that sexual relationships could serve as a substitute measurement for familial proximity in the absence of the latter 47 a possible contributing element could be the comparatively inadequate monitoring by parents in households with single parents there exists a connection between parental supervision and the composition of a family 4849 the strengths of this study systematic review and metaanalysis methodologies were used which allowed the researchers to synthesize data from multiple studies to provide a more comprehensive understanding of early initiation of sexual intercourse among ethiopian youth and the study has a rigorous inclusion and exclusion criteria which ensures the quality of the studies included in the analysis this study also has some limitations the study is limited to studies published in english and could have missed studies conducted in other languages which may have been relevant to the study and the studies included in the review often had different definitions of early initiation of sexual intercourse which may have contributed to variations in the prevalence estimates conclusions the data availability the datasets used andor analyzed during the current study available from the corresponding author on reasonable request abbreviations declarations ethical approval and consent ethical approval will not be required since this is a systematic review of already published data all methods and materials are performed according to the guidelines

background early sexual initiation refers to engaging in sexual activity at a young age typically before the age of 18 even though many studies have been conducted in ethiopia the result is inconsistent between studies in the study area the pooled prevalence and associated factors of early initiation of sexual intercourse among youth were not done before therefore this study aimed to determine the pooled prevalence and associated factors of early initiation of sexual intercourse among youth in ethiopiathis study used a systematic review and metaanalysis of studies conducted from 2008 to 2022 in ethiopia the preferred reporting items for systematic reviews and metaanalyses prisma guidelines were followed pubmed cochrane library hinari and google scholar electronic databases were searched the analysis was performed using stata 17 software heterogeneity and publication bias were assessed using forest plots i 2 cochrans q statistics and funnel plots egger test and begg rank tests respectively duval and tweedies trim and fill method was also performed to adjust the pooled estimate pooled analysis was conducted using the inversevariance fixedeffects model results a total of 10 articles were included in this systematic review and metaanalysis the pooled prevalence of early initiation of sexual intercourse among youth in ethiopia was 247 95 ci 10

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introduction a substantial worldwide decline in maternal and neonatal mortality by nearly half has been observed in the last 2 decades 1 2 3 this reduction was driven by the adoption of the world health priorities of the millennium development goals 3 which included the offer of family planning counselling and prevention of adolescent childbearing coverage of antenatal support assistance of skilled health personnel at delivery and access to emergency obstetric care on the other hand there are still medical conditions related with infant deaths these conditions include different disorders influencing the duration of the gestation and fetal growth that continue to have deleterious effects on the evolution of the pregnancy several terms are used to describe infants with low birth weights for their gestational age these include fetal or intrauterine growth restriction and small for gestational age the two terms are not synonymous fgriugr refers to the fetus who does not achieve the expected in utero growth potential due to genetic or environmental factors sga is defined by birth weight below the 10th percentile for gestational age perinatal mortality is higher in sga infants compared with neonates born appropriate for gestational age this association is present in both term and preterm infants 4 5 6 7 8 9 10 sga is responsible for around 22 of neonatal deaths in lowand middleincome countries 11 it is also a cause of a wide range of shortand longterm complications 10 sga infants have a higher risk of morbidity and stunting in childhood and through adulthood are predisposed to develop chronic diseases like obesity type 2 diabetes mellitus coronary artery disease and stroke 1213 sga children have significantly higher systolic diastolic and mean blood pressure than aga children 14 delivering an sga infant is also associated with maternal atherosclerotic cardiovascular disease risk 15 many factors affect the duration of gestation and fetal growth and thus the birth weight these factors depend on the characteristics of the infant the mother or the physical environment and play an important role in determining the future health of the neonate 16 sga infants consist of constitutionally normal small neonates as well as of intrauterine growth restricted infants due to genetic or environmental factors known constitutional factors that influence the occurrence of sga include maternal height weight ethnicity and parity 17 moreover extremes of maternal age multiple pregnancies obstetric complications maternal conditions infections and nutritional status 18 also have an effect on the development of sga paternal adverse birth outcome particularly sga is a modest risk factor for sga independent of maternal risk status 19 in the last decade studies have highlighted the link between exposure to preconception stressful life events 20 and substance use such as alcohol consumption and smoking 21 with sga pregnancies prenatal stress seems to lead to alterations in the brain of the newborn at multiple levels from molecular and cellular to structural 22 on the other hand research regarding the associations of social support and maternal life satisfaction with sga is scarcer a study 23 by the anhui medical university in china found no association between social support and the risk of delivering an sga infant the generation r study 24 is a prospective populationbased mother and child cohort in the netherlands with 6334 mothers living in the rotterdam area this study that analyzes associations between maternal physical and mental healthrelated quality of life in early mid and late pregnancy and adverse birth outcomes but does not confirm the hypothesis that worse physical or mental hrqol is associated with sga the objective of this study is to analyze the relationships between mothers´ socioeconomic and lifestyle factors social support and life satisfaction and the delivery of an infant with sga in a birth cohort in northeastern germany materials and methods study population the survey of neonates in pomerania the present data were derived from the populationbased birth cohort study survey of neonates in pomerania 25 the snip study collected comprehensive data on pregnancies mothers and their offspring in western pomerania from march 2003 until november 2008 details have been previously reported by ebner and colleagues 2010 25 in short all women giving birth during the study period and being registered as a resident of the study area defined by zip codes 1738917999 northeastern germany were asked to participate eligible women were asked for written informed consent from the 7339 births within the region during the study period 7024 mothers met eligibility criteria exclusion criteria comprised women with insufficient language skills death mothers who gave up their newborn for adoption newborns with congenital anomalies and other reasons an sga infant was defined as a neonate with a birth weight below the 10th percentile for gestational age based on genderspecific references for birth weight from the german perinatal survey of 20072011 26 an appropriate for gestational age infant was defined 1 3 as a neonate with a birth weight between the 10th and the 90th percentile for gestational age based on genderspecific references for birth weight from the german perinatal survey of 20072011 26 a large for gestational age infant was defined as a neonate with a birth weight above the 90th percentile for gestational age based on genderspecific references for birth weight from the german perinatal survey of 20072011 26 of those eligible consent was obtained in 5401 for mothers declining to participate or women admitted to the maternity ward who we were unable to contact an anonymous minimum dataset was abstracted comprising data on the health status of the newborn but without detailed information about environmental parameters a nonresponder analysis revealed no meaningful selection bias 25 for the present study we excluded mothers with multiple pregnancies younger than 18 years of age and those who delivered infants classified as large for gestational age the final analytical sample comprised 4598 mothers aged 18 to 46 years and their respective infants all mothers who participated in the study gave written informed consent the study was approved by the ethics committee of the medical faculty of the ernstmoritzarndt university greifswald and complies with the declaration of helsinki characteristics of the study sample detailed data on the health status of the mother the newborn the pregnancy socioeconomic and lifestyle factors and life satisfaction were obtained via interview standardized questionnaires and medical records having obtained written consent a trained physician performed a facetoface interview and then handed out the selfadministered questionnaire the interviewer also collected the required information from medical records these were the prenatal care booklet and hospital files the maternal age height prepregnancy body mass index bmi calculated as weight height 2 weight gain during pregnancy in kg number of previous pregnancies and prior pregnancy losses were obtained from the prenatal fig 1 participants flowchart care booklet in germany every pregnant woman visiting her gynecologist receives a prenatal care booklet where this information is recorded the maternal place of birth was asked in the facetoface interview pregnancy outcomes the gestational age was determined from the best obstetric estimate and was recorded from the hospital files the infants birth weight in g birth length in cm head circumference in cm gender of the infant mode of delivery and whether the newborn was admitted to neonatal care were collected from the hospital files maternal socioeconomic social support and lifestyle factors variables women were asked about their socioeconomic status and alcohol and tobacco usage prior to and during their pregnancies through selfadministered questionnaires the demographic standards for germany 27 were used for socioeconomic variables including education income employment before pregnancy and family status at birth furthermore questions focused on the social integration of the mothers regarding the number of people they could rely on in case of an emergency and number of friendships outside the household they would not wish to relinquish the alcohol use disorders identification testconsumption 2829 was used to assess alcohol consumption selfreported responses were categorized into three mutually exclusive categories no maternal use before and during the pregnancy maternal use before the pregnancy or current use in the pregnancy the fagerström test of nicotine dependence 3031 was used for smoking selfreported responses were categorized into four mutually exclusive categories no maternal use before and during the pregnancy maternal use before the pregnancy quit during pregnancy or current use in the pregnancy maternal life satisfaction through selfadministered questionnaires the mothers reported their satisfaction with regard to their living situation in general as well as their housing financial leisure time health family and working situation and relationships with friends neighbors and acquaintances satisfaction with each item was assessed with the question to what extent are you satisfied with the item below and a scale ranging from 1 to 7 32 for a better presentation of the data we categorized the answers into three groups dissatisfied which included completely dissatisfied very dissatisfied and dissatisfied neither dissatisfied nor satisfied and satisfied which included satisfied very satisfied and completely satisfied statistical methods all data were stored using a microsoft access 2002 database descriptive data were reported as the median for continuous variables and as percentage for categorical variables stratified by birth weight for gestational age to analyze possible differences between the subgroups p values were calculated using the chisquared test for categorical variables and the wilcoxon ranksum tests for continuous variables associations of maternal lifestyle and social factors as well as maternal life satisfaction with the delivery of an sga infant were analyzed by logistic regression models adjusted for height of the mother which is considered the most important constitutional factor to influence the incidence of a small for gestational age infant 33 34 35 all analyses were carried out with stata 161 differences between the overall totals for individual dimensions resulted from slightly different proportions of missing answers all percentages given related to the number of questionnaires eligible for the particular dimension analyzed results characteristics of all study participants stratified by birth weight for gestational age are provided in table 1 mothers who delivered an sga infant were younger shorter more commonly either underweight or obese and gained less weight during their pregnancy when compared to mothers who delivered an aga infant women with pregnancies complicated by sga were more frequently nulliparous there were similar frequencies of place of birth of the mother and prior pregnancy loss between mothers of sga and aga infants associations of the pregnancy outcomes with birth weight for gestational age overall 71 of the infants were born preterm with the gestational age at delivery gender of the infant and mode of delivery similar in sga and aga pregnancies the median difference of weight between sga and aga infants was around 680 g the median difference of length was two cm and the median difference of head circumference was one cm between both groups moreover sga infants were twice as often admitted to neonatal care compared to infants born aga associations of the maternal socioeconomic social support and lifestyle factors with birth weight for gestational age women who delivered sga infants had fewer years of education when compared with mothers of aga neonates while one quarter of them had fewer than 10 years of education twice as many of the women who delivered aga infants held university degrees after logistic regression analysis adjusted for the height of the mother a mother with less than 10 years of school education had an or of 223 95 confidence interval 144 to 346 of having an sga infant while a high proportion of all pregnant women continued smoking during their pregnancies the prevalence of current smoking of the sga pregnancies was twice as frequent when compared to aga pregnancies after logistic regression analysis adjusted for the height of the mother a mother who continued to smoke during pregnancy had an or of 268 of having an sga infant on the other hand there was no association between the employment or unemployment of the mother before pregnancy the monthly income the family status at birth the number of friendships outside the household that the mother would not wish to relinquish the number of people that the mother could rely on in case of an emergency and alcohol consumption before or during the pregnancy with the delivery of an sga infant associations of life satisfaction with birth weight for gestational age women who delivered sga infants were more frequently dissatisfied with their employment and financial status and with their living situation in general on the other hand there were no associations between the mother´s satisfaction with their housing situation leisure time health situation family situation and relationships with friends neighbors and acquaintances and the birth weight for gestational age discussion in this populationbased cohort we found numerous associations between maternal socioeconomic and lifestyle factors and life satisfaction and the risk of delivering an sga infant women who delivered sga infants were younger shorter more commonly both underweight and obese gained less weight during their pregnancy and were more frequently nulliparous beyond these already known constitutional risk factors 34 we found that in women who had sga infants the number of years of education was lower and the proportion of active smokers during pregnancy was twice as high contrary to the association between sga and school education we found that the monthly income did not show an effect on the chance of having a sga infant we believe the explanation for these results is that the monthly income is a potentially endogenous variable it might correlate with unobservable characteristics and the parental education effect is transmitted to a certain degree through income we believe these are important aspects that require further studies 36 moreover the mothers of sga infants were more frequently dissatisfied with their work financial and living situation in general we believe that these associations might explain the previously described social determinants of health during a pregnancy wherein social factors can influence the fetal development and are associated with the birth of an sga infant in the context of the published literature prior studies 202123343738 have demonstrated an association of specific maternal demographic and behavioral factors with the delivery of an sga infant however as far as we know this is the first populationbased study that analyzed the associations of satisfaction with the living situation in general as well as individual dimensions such as housing financial leisure time health family and working situation and relations with friends neighbors and acquaintances with an incident sga birth short stature 34 low weight before pregnancy 343839 low weight gain during pregnancy 3438 lower educational status 23 lower income 23 and maternal smoking 3438 are factors that have previously been consistently associated with the risk of delivering an sga infant and are in line with our results other risk factors like maternal age 343840 socioeconomic factors 343840 and alcohol consumption 343840 have been inconsistently identified across studies social support was assessed by the chinese revised edition of the social support scale in a study 23 with 1800 women aged 2034 years who delivered after 32 weeks gestation in the anhui medical university in china there was no association between social support and the risk of delivering an sga infant these results are consistent with our results furthermore an analysis from the consecutive pregnancies study 34 a retrospective cohort study which included 27077 women who were nulliparous and had singleton deliveries also showed that raceethnicity marital or insurance status or alcohol consumption were not associated with sga contrary to our study where we did not find an association between alcohol consumption and sga birth a casecontrol study 41 with 518 pairs of pregnant spanish women found that alcohol consumption of less than 4 g day appeared to exert a protective effect against the delivery of an sga newborn in comparison to women reporting no alcohol intake during the pregnancy a possible explanation for the different results might be related to biased selection or residual confounding in contrast to the results of our study the generation r study 24 did not confirm the hypothesis that worse physical or mental healthrelated quality of life is associated with adverse birth outcomes including sga hrqol is a measure of the personal perception of the value and quality of life as influenced by disease injury and treatment the hrqol was measured using the 12item short form survey that covers eight areas physical functioning role limitations due to physical problems bodily pain general health vitality social functioning role limitations due to emotional problems and perceived mental health physical and mental component summary scores were calculated a possible explanation for the results might be related to the relatively healthy and educated women enrolled in the generation r study when compared to the general dutch population a study examined child hair cortisol concentration and maternal stress during pregnancy in a lowincome sample consisting of 77 healthy motherchildren pairs 42 maternal stress was measured with the perceived stress scale during pregnancy child hcc was measured approximately four years later regression analysis revealed that child hcc was not significantly predicted by maternal perceived stress a study in one hospital in taiwan 43 with 198 pregnant women without complications assessed the maternal quality of life monthly beginning between 25 and 29 gestational weeks until 1 month postpartum the duke health profile was used to measure quality of life the duke is a 17item threepoint measure of the physical mental social general and perceived health the results of the study are consistent with our results they suggest that poor maternal physical and social health at late pregnancy could predict preterm birth and that low maternal health scores at earlier pregnancy tended to predict infants born with a low birthweight many factors affect the fetal growth and thus the birth weight for gestational age they relate to the infant the mother and the physical environment and play an important role in determining the future health of the infant 16 we believe that the social and psychological determinants that are associated with a healthy pregnancy which we are able to document as an adequate birth weight for the gestational age vary depending on the population analyzed 44 this might help to explain why the incidence and prevalence of sga varies between different analyzed populations 11 for example the incidence of sga in developing countries is twice as high compared to developed countries 1145 our results suggest the importance of documenting and analyzing not only the already known constitutional risk factors but also the possible maternal life satisfaction aspects in relation to the incidence of sga births snip comprises the population of a sparsely populated area in northeastern germany a population still adapting to social and economic hardships since the german reunification in 1990 25 the analyzed population of western pomerania lives in a region with higher unemployment and poverty risk rates than the national average 4647 and presents the lowest life expectancy in germany 4647 although in the past century neonatal mortality in germany decreased similarly to other western nations these changes were less pronounced in east germany 48 if a correlation between psychosocial risk factors in pregnant women and birth weight is confirmed it might be possible to develop screening tools to identify women with increased risk for developing a pregnancy with sga fetuses and provide the necessary support to avoid this complication strengths and limitations the main strength of this study is the use of a large sample which includes the majority of the births in a specific population over a period of time furthermore we used specific birth weight charts for the analyzed population this reduces the risk of potential misclassification as birth weight charts influence the classification and incidence of sga 49 study limitations include the difficulty in obtaining valid and reliable data on alcohol intake and smoking during pregnancy although this was mitigated by the use of validated questionnaires the auditc 28 and the ftnd26 30 misclassification must always be considered especially during pregnancy because of socially desirable answers moreover the questionnaires in our study were completed between the delivery and hospital discharge so that memory bias cannot be ruled out another limitation of the study is the exclusion of participants with missing data which might limit the generalizability of the results to some extent there are also other potential confounding variables that were not included in the analyses for example diet related factors the associations could be cofounded by other unfavorable lifestyle or medical factors conclusions while previous studies have shown the relative influence of environmental and genetic factors that explain the variation in birth weight our findings showed an association of maternal lower educational status smoking and life dissatisfaction with delivery of an sga infant future studies should analyze whether interventions designed to support women exposed to these risk factors might avoid the occurrence of sga births and their complications data availability the data of the snipstudy is publicly available via fvcm med unigreif swald de this is a data repository where any researcher can register and find data dictionary as well as an online application tool for getting access to data upon an application by registered users the research cooperation community medicine of the university of greifswald germany which is funded by the federal ministry of education and research decides on granting access to the data based on scientific guidelines author contributions gp protocolproject development data analysis manuscript writingediting ti data collection or management data analysis jfa data analysis manuscript writingediting usm data analysis manuscript writingediting hjg protocolproject development manuscript writingediting md protocolproject development manuscript writingediting mh protocolproject development data collection or management ael protocolproject development data collection or management mrpm protocolproject development data analysis manuscript writingediting all authors commented on previous versions of the manuscript all authors read and approved the final manuscript funding ethics approval this study was performed in line with the principles of the declaration of helsinki approval was granted by the ethics committee of the medical faculty of the ernstmoritzarndt university greifswald in february 2002 all methods were carried out in accordance with relevant guidelines and regulations consent to participate written informed consent was obtained from all subjects andor their parent or legal guardian open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons licence and indicate if changes were made the images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit creat iveco mmons org licen ses by4 0 publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and 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the aim is to investigate the associations of the mothers socioeconomic and lifestyle factors and life satisfaction with the delivery of a small for gestational age sga infant methods data from 4598 participants of the populationbased birth cohort study survey of neonates in pomerania snip including comprehensive information on pregnancies mothers and their offspring in western pomerania germany were used in this study the associations were analyzed using linear and logistic regression models results after logistic regression analysis adjusted for height of the mother women who delivered sga infants had lower education p 001 and smoked more frequently during pregnancy p 001 compared with mothers of adequate for gestational age aga neonates a mother with less than 10 years of education and one who continued smoking during pregnancy had an odds ratio or of 223 95 confidence interval ci 144 to 346 and 268 95 ci 206349 of having an sga infant respectively there was no association between the employment of the mother p 028 the monthly income p 009 the family status p 080 the number of friendships outside the household that the mother would not wish to relinquish p 047 the number of people that she could rely on in case of an emergency p 075 or alcohol consumption prior to p 014 or during the pregnancy p 099 with sga finally women who delivered sga infants were more frequently dissatisfied with their employment p 003 and financial status p 001 conclusions women who delivered sga infants had more associated socioeconomic and lifestyle risk factors and were more frequently dissatisfied with their life conditions than mothers of aga neonates

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comunicación breve brief communication cabieses b tunstall h immigrant health workers in chile is there a latin american brain drain rev panam salud publica 2012321617 suggested citation immigrant health workers in chile is there a latin american brain drain baltica cabieses 1 and helena tunstall 2 the phenomenon known as brain drain has been defined as the international recruitment and migration of high skilled workers especially health workers from less advantaged countries to more advantaged ones an increasing number of medical doctors nurses and other health workers have been moving across national borders to pursue new opportunities and better career prospects in 2006 in the united kingdom about one in three physicians in the national health service were from another country and there were more nurses from malawi working in manchester alone than there were in malawi worldwide the rate of brain drain has risen in recent decades research suggests a large number of less developed countries are affected by this phenomenon including the philippines and countries from subsaharan africa a loss of skilled human resources has also been reported in latin america as workers travel abroad seeking a better life research by özden found that the extent of migration of workers with at least a college degree is extremely high for many countries in the region this is especially true for some of the smaller most research on the phenomenon of brain drain has focused on movement between the least developed and most highly developed countries therefore the significance of patterns of migration to middleincome countries such as those in latin america is less clear the aim of this study was to outline key features of international health worker brain drain to chile to promote discussion and further research on this phenomenon as it pertains to the latin american region the study compared immigrant health workers living in chile to both chileanborn health workers and other immigrants living in chile using a qualitative nationwide dataset demographic socioeconomic and healthrelated variables were included in the analyses which were weighted by population to obtain nationally representative estimates in 2009 immigrant health workers represented 22 of all health personnel and 26 of all resident immigrants in the country while most immigrant health workers had a universitylevel education about 25 had only a high schoollevel education or less there was no statistically significant difference between the distribution of immigrant health workers household income and that of chileanborn health workers a significantly higher proportion of the immigrant group reported no entitlement to health care provision while the results of this study do not indicate a significant international health worker brain drain to chile they do suggest distinctive patterns of migration within the latin american region future studies in chile could confirm the validity of these results using a larger sample of immigrant health workers and less developed countries that fail to establish adequate labor market opportunities for educated workers as a consequence collegeeducated workers are overrepresented among the migrants from these countries compared to their overall share in the native population the loss of skilled health care staff in less developed countries is likely to have an extremely negative impact on those countries health care system international debate has developed over whether the recruitment of health workers from developing countries by developed countries is ethically justifiable in 2011 the world health organization drafted the who global code of practice on the international recruitment of health personnel a groundbreaking instrument that marks the first time that who member states have used the constitutional authority of the organization to develop a nonbinding code in 30 years this codewhich establishes and promotes voluntary principles and practices for the ethical international recruitment of health personnel and the strengthening of health systems and has been adopted by all 193 who member stateshas created an urgent need to improve the available data on the brain drain of health personnel as most research on brain drain has focused on the movement of skilled workers between the least and most highly developed countries there is a particular need for data on patterns of health worker migration to middleincome countries such as those in latin america in past decades migrant destination countries have favored policies seeking to attract highly skilled workers from abroad with the recent global economic crisis however these policiesand the dynamics of brain drainmay have changed cerna recently explored this issue in five regions asia australasia europe the middle east and north america her findings showed that with the onset of the crisis and increasing pressure to protect nativeborn workers from rising unemployment many governments have introduced restrictions on highly skilled migration the effect of the financial crisis has not been explored in relation to immigration to chile however despite a relative increase in the immigration rate to this country in recent years according to the literature latin american intraregional migration has increased significantly over the past three decades while both the educational background and employment prospects of international immigrants in this region vary according to the conditions and circumstances under which workers migrate they tend to depend on the demand of the labor markets these variables shape the dynamics of the brain drain phenomenon in the latin american region including the migration of skilled health workers while significant research has been conducted on the overall brain drain in latin america little evidence has been generated on skilled health workers despite the growing and complex health needs of the latin american population moreover to the best of the current authors knowledge no prior study has focused specifically on international health worker brain drain to chile chile has attracted increasing numbers of immigrants and in 2006 more than 70 of them came from other latin american countriesmostly argentina bolivia ecuador and peru the socioeconomic characteristics of immigrants in chile have changed in recent decades with a relative decrease of highly educated people a phenomenon that has been accompanied by a relative increase in the migration of chileanborn people for study purposes particularly at the university and postgraduate level although immigrants in chile may be less educated than in the past they continue to contribute to the economic development of the country while a proportion of them make a direct contribution to health care services the actual rates are difficult to estimate therefore the volume of international health worker brain drain to chile remains unknown in addition the characteristics of immigrant health workers in chile have not been researched so it is not clear whether they represent a relatively privileged or vulnerable group within the chilean population the aim of this study was to outline key features of the brain drain of international health workers to chile to promote discussion and further research on overall brain drain in latin america this article describes the volume of international health workers migrating to chile and their sociodemographic and health characteristics materials and methods to assess the volume and characteristics of immigrant health workers resident in chile this study compared that group to both chileanborn health workers and other immigrants living in chile the only quantitative nationwide dataset available in chile for this purpose was the 2009 national socioeconomic characterization survey the casen survey is a large anonymous nationally representative household survey conducted every three years in chile that aims to describe the socioeconomic and general health conditions of the chilean population since 2006 the casen survey has covered migration status as well as other more longstanding socioeconomic and health status variables a detailed methodological explanation of this survey can be found elsewhere the 2009 casen dataset was downloaded by the authors following the approval of a request made through the surveys official web site in march 2011 for this study health workers were defined using casen data collected in response to the question in what labor sector do you work those who chose medicine dentistry and other health services were included in the study analysis it should be noted that a wide range of health workers with variable levels of skills and education fall into this category migrant status was defined based on the response to the question where did your mother live when you were born if survey participants chose the response in a different country from chile they were categorized as international immigrants and compared to the other categories combined to allow for broad exploration of the characteristics and living conditions of immigrant health workers in chile a wide range of variables were analyzed including demographic socioeconomic and healthrelated it should be noted that the health care system in chile is complex comprising both public and private systems that have minimal interaction and collaboration the public health care system covers about 70 of the population while the private system which includes about 150 different insurance plans covers about 30 descriptive and comparative analysis was conducted using stata 100 due to the complex sampling strategy used in the survey the results were weighted by population to ensure nationally representative estimates crude proportions and means were estimated and chisquare tests were used to estimate differences between groups based on 95 confidence intervals results profile of resident immigrant health workers in chile in 2009 from the 246 924 total participants who responded to the casen survey in 2009 2 225 reported being health workers and 1 829 were international immigrants out of all health workers 49 were international immigrants and 2 176 reported being chileanborn therefore in 2009 immigrant health workers represented 22 of all health personnel in chile and 26 of all resident immigrants in the country just under half of all immigrant health workers came from canada and 4524 originated from latin america among latin american immigrants bolivia ecuador and mexico were the most common countries of origin reported for health workers whereas among the total immigrant population in chile the most frequent cited ones were argentina bolivia and peru a comparison of different occupational groups indicated that immigrants in chile were more overrepresented versus the nativeborn population in certain occupations for example as shown in table 2 there are significantly higher proportions of immigrants with contracts for managerial positions and in domestic service versus the chileanborn population compared to their chileanborn counterparts immigrant health workers living in chile in 2009 were more likely to be younger female and married with an ethnic background and living in an urban area however no statistically significant differences were found between the two groups for these variables there was a significantly higher proportion of immigrant health workers versus chileanborn health workers in both the santiago metropolitan area and the central area of the country with a very weak presence in the rest of chile as shown in table 2 there were no significant differences in the educational level of immigrant health workers versus chileanborn health workers and almost half of both groups had a universitylevel education however a significant minority of immigrant health workers were low skilled and poorly educated with about 25 having only high schoollevel or less education a significantly lower proportion of health workers were in the poorest household income quintile compared to nonhealth workers in each of the populations under study there were no statistically significant differences in the distribution of immigrant health workers household income versus that of chileanborn health workers similar results were found when estimating the absolute mean household income per capita by quintile among immigrant health workers versus chileanborn health workers all immigrant health workers were employed at the time of the study and a higher but a nonstatistically significant proportion of them reported having a contract for a managerial position working in the private sector or being selfemployed versus the chileanborn health workers immigrant health workers reported their overall selfperceived health status as goodvery good at a slightly higher rate than their chileanborn counterparts but this difference was not statistically significant while no immigrant health workers reported having a disability their overall mean number of health care contacts in the past three months was slightly higher than that of chileanborn health workers in addition a significantly higher proportion of immigrant health workers reported having no entitlement to health care provision compared to the chileanborn health workers among those who were entitled to health care services a significantly lower proportion of immigrant health workers had access to the public health care system compared to their chileanborn counterparts a comparison was also made between immigrant health workers and all immigrants living in chile compared to the latter group immigrant health workers were more likely to be of working age and a currently active worker with a managerial contract and to have a technical or universitylevel education and a higher household income per capita immigrant health workers reported a significantly lower rate of public freeofcharge health insurance in chile versus other sectors of the international immigrant population discussion based on the 2009 casen survey results analyzed in this study there is little evidence of an international health worker brain drain to chile because 1 immigrant health workers represented a small proportion of the total populations of both health workers and immigrants residing in the country and 2 the characteristics of the immigrant health worker population in 2009 did not meet the classic definition of the term while the majority of immigrant health workers participating in the survey selfreported as highly educated a significant minority did not with slightly more than 25 reporting only a high schoollevel education or less in addition almost half came from a more developed country brief communication cabieses and tunstall • immigrant health workers in chile latin american brain drain while the majority of the remainder came from other latin american countries only some of which are significantly less advantaged than chile this latter characteristic was an interesting and unexpected feature that illustrates the complexity of migration to chile which includes individuals from highincome stable countries as well as those from lowerincome countries with socioeconomic issues or political conflict such as bolivia ecuador and mexico while the results of the analysis did not support international health worker brain drain to chile they did suggest that immigrant health workers are a distinctive subset of both the health worker and international immigrant populations in chile with some significant differences in their sociodemographic and health profile for example immigrant health workers were more likely than other international immigrant groups to be highly educated and less likely to fall into the poorest household income quintiles in addition most immigrant health personnel were not entitled to any health care service provision as opposed to chileanborn health workers finally variation in the country of origin of immigrant health workers living in chile adds another layer of complexity to the patterns of migration along with the wide range of their cultural backgrounds which is likely to result in differences in immigrants expectations and adaptation to chile over time other relevant yet unmeasured variables such as reasons for immigration socioeconomic and health status prior to migration adaptation to chile after arrival length of stay in the country variations in legal status and contractual status and experiences of stigma and discrimination could be explored in future research the results of this study complement evidence from the significant amount of research that has been conducted on the brain drain phenomenon in latin america in the past as shown in prior studies migration patterns in the region are deeply connected with economic social and political dynamics at both the country and global level this study is a first step toward understanding these dynamics in chile conclusions while this study of immigrant health workers does not identify a significant brain drain to chile it does suggest that there are distinctive patterns of international immigration in the latin american region future studies in chile could confirm the validity of these results using a larger sample of immigrant health workers a health worker survey in particular could help to disentangle many of the characteristics observed in this study in addition longitudinal analysis following immigrant health workers since before their arrival and throughout the migration process could contribute to a new perspective of the brain drain of health workers in the latin american region southern areas most likely due to the centralization of the labor force and labor opportunities in chile this centralization feature is widely recognized and remains a relevant issue to address at the policy level for various reasons including the demographic socioeconomic and health inequities that exist

rev panam salud publica 32 2 2012cabieses and tunstall • immigrant health workers in chile latin american brain drain

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background each year in the united states approximately 100000 new patients are diagnosed with endstage kidney disease which for many people results in a life on dialysis the incidence of eskd is highest among racial and ethnic minorities black and latino patients have 143 times the rate of eskd respectively black and latino patients are more likely to start dialysis at a younger age and are less likely to be placed on a kidney transplant list consequently black and latino patients spend a considerably greater proportion of their lives on dialysis the number of people who are on dialysis is likely to increase given the rapidly growing epidemic of diabetes a leading cause of eskd among racial and ethnic minority populations if these current trends continue by the year 2030 the number of patients with eskd may reach over two million primary prevention of eskd is critical to halting this trend however for those who develop eskd understanding factors that influence their overall experience on dialysis is essential to developing targeted solutions and preserving their quality of life in recent years there has been a paradigm shift toward greater focus on the patient experience national agencies such as the patientcentered outcomes research institute and the centres for medicare medicaid services have called for research and programmes that improve quality of life and the dialysis experience for patients understanding patients experiences is paramount to developing patientcentered and responsive solutions this study sought to gain a better understanding of the psychosocial context of life on dialysis from the perspectives of black and latino patients the ultimate goal is to use these data to inform clinical guidelines to set new priority areas for research and create innovative patientcentered programmes that address the values beliefs and priorities of patients who are from racial and ethnic minorities methods qualitative research is an approach that is wellsuited for understanding the social and contextual factors that affect the psychosocial health of patients on dialysis this study uses descriptive phenomenology a qualitative approach that aims to capture a specific phenomenon or event from the perspectives of those who have experienced it phenomenology allows for an indepth look into the lives of patients on dialysis and elicits their perspectives and interpretations of psychosocial challenges that they have endured and adjustments that they have made study setting and participants this study was conducted at the nephrology foundation of brooklyn a dialysis centre located in east new york brooklyn east new york is a medically underserved community onethird of the residents live below the poverty line and onefourth have not completed high school participants were accrued through purposive sampling an approach used to select study subjects that can provide the greatest insight into the research question a purposive sample is a nonprobability sample whereby participants are selected because they are deemed as having the most knowledge understanding and experience of the phenomenon of interest for the purpose of this study participants were selected specifically because they had been on dialysis and thus were able to provide greater insight into different aspects of life on dialysis the advice of providers nurses and social workers at the dialysis centre were sought in identifying patients who would be willing to participate in individual interviews and share their experiences patients who were identified were approached by a member of the research team to obtain informed consent participants were adults who had been on dialysis for more than six months were referred by their provider and who provided consent ineligible participants were those who were feeling ill at the time of dialysis or who did not provide consent members of the research team included providers nurses researchers and community advocates for dialysis patients this team developed and piloted sample interview questions and probes a review of the literature was conducted to identify sample interview questions that had been included in previous qualitative studies on patients experiences on dialysis a final set of items were developed and was administered to participants by the study coprincipal investigators it was explained to participants that this study was to better understand their experiences on dialysis and to learn what health professionals can do to improve the lives and overall quality of life of patients who are on dialysis the following openended were asked to stimulate a discussion 1 what are some of the challenges that you have experienced as a result of being on dialysis 2 what do people on dialysis need in their lives in order to be healthier live healthier or just be more comfortable with dialysis 3 what are some of the things doctors or nurses need to know in order for them to help patients on dialysis and their family members cope with dialysis in order to give participants sufficient time to talk the number of questions were limited and designed to be broad brief and openended these items often led to the discussion of other topics such as what changes they had to make to deal with dialysis and the impact that dialysis had on interactions with family analytic approach individual openended qualitative interviews were conducted at the chairside while patients were undergoing dialysis the duration of the interviews ranged from 20 to 90 minutes the variation in duration was due to the fact that some participants provided very detailed and indepth responses while others provide more succinct and precise responses the interviewer sat in a chair that was adjacent to the participant participants were asked to describe their experiences on dialysis to discuss challenges that they faced accommodations they made and to share recommendations on how the experience of dialysis can be improved for other patients and their family all interviews were conducted in english all interviews were audiotaped and responses were transcribed verbatim a series of standard qualitative techniques were used for data analysis responses were read linebyline and codes were then assigned to each response codes are descriptive labels or tags that represent key concepts conveyed in the data codes can be actual responses selected words from the transcripts or words that represent key concepts similar codes were then grouped into categories each category was then reviewed to identify underlying dimensions or subcategories that could be grouped to form new categories all final categories were reviewed and overarching themes were generated themes are recurring and unifying statements that represent the overall meaning or essence of the lived experience of dialysis in order to ensure trustworthiness of data detailed notes of all interviews and coding processes were maintained as field notes when there were discordant views regarding the interpretation of data the team reviewed the raw data and new categories were derived until consensus was reached study findings are reported in accordance with the consolidated criteria for reporting qualitative studies the study was reviewed and approved by the institutional review board for the responsible and ethical conduct of research the transition to dialysis is abrupt and unexpected there was a common sentiment among participants that the onset of dialysis was abrupt and unexpected some participants did not know that they had kidney failure others attributed their symptoms to other illnesses or conditions in several instances the first dialysis was done emergently in the hospital setting the following responses illustrate this finding for me i didnt know i had kidney failure until i had kidney failure dialysis was just thrown on me when i was in the hospital the doctor said you have to start dialysis tomorrow i did not even know what dialysis was overall there was a feeling of being illprepared for what was about to transpire as participants discussed the onset of dialysis they also provided their perspectives on how to better prepare other patients as an example one participant stated doctors can help people transition into this new way of life more easily the whole experience is traumatic participants were aware of the precursors of kidney disease such as diabetes and hypertension however they perceived a lack of information on eskd and dialysis itself one example is all of the pamphlets are about high blood pressure heart disease diabetes there is never nothing about kidney failure and i really think there needs to be more put out there denial is often an initial response although the actual placement on dialysis seemed abrupt some participants confided that they had been told of their need for dialysis but were initially in denial one participant simply stated they warned me had i listened maybe i would not be here today another example that supports the theme of denial is the following i was in denial i said no thats not me thats for other people then a year later my feet started to swell i couldnt walk 10 feet i could not put on shoes or tie them up i had excessive weight gain eventually when they did it they did emergency dialysis forget the past and press forward there was a theme of resignation to being on dialysis as a new normal way of life participants said they learned how to just deal withitoneparticipant statedits not difficulti am resigned to the fact that this is now my life i had a few days to think about it this appeared to be a conscious way of dealing with the reality of being on dialysis a recurring theme was forgetting the past and pressing forward there was an undercurrent of completely abandoning their goals rather than simply delaying or deferring their goals some exemplary responses include so i guess i am kind of going with the flow instead of being ambitious and having all these goals that you know you cant you know what i mean the only way to survive this is to basically forget about your past and start fresh from here and go forward dialysis changes everything and impacts the entire family participants described how being on dialysis meant changing almost every aspect of their life they described the challenges and psychosocial context of health behaviour change they described the dynamic social and cultural factors that influenced the ability to make lifestyle modifications participants had to make modifications in their dietary and fluid intake participants described the challenges of giving up certain foods that they were accustomed to eating the restrictions of a lot of foods like cheese and bananas i used to love bananas that kind of disappointed me a little bit that diet is almost unrealistic how can you tell someone to stop eating bread and they grew up on bread my problem is liquids as long as i have been on dialysis that is the one thing that is the most difficult i have tried everything i have tried sucking on ice buying a certain water bottle a certain size cup the influence of cultural practices was described participants shared some of their eating patterns that were deeply rooted in cultural norms the following examples describe the cultural factors that may influence the process of making dietary modifications i am from west indian descent so there are certain things i cant have anymore that i have loved since i was little all the spicy stuff the hot curry stuff you know the macaroni and cheese you just cant have it anymore i am puerto rican you know and the rice and beans pasteles now you know i have pasteles just once a year participants described social determinants that presented barriers to making and adhering to lifestyle modifications participants described the challenge of balancing the need to eat healthy meals with other basic necessities such as paying rent paying for transportation or owning a telephone the true question is could we truly afford to eat healthy the answer would be no it is more expensive to eat healthy than it is to eat garbage and to make the belly full my husband just lost his job and its been really tough getting to the food pantry is tough and some of them are closed i dont have carfare for a bus i cant get to where i have to go within the first 3 days of getting our checks the money is gone i pay the rent and our phone because that is so important in describing how dialysis changed all aspects of their lives there were several discussions on the impact of dialysis on the entire family unit participants expressed gratitude for the involvement of family members in their care however juxtaposed with the tremendous appreciation for the critical role that family members played was a concern of being a burden sometimes i just cry and rather die than go through this what could i do its tough on my family my children and my husband its kind of tough i feel so sorry for my husband he has to spend a lot of time with me to give me my medication my insulin because i have diabetes being on dialysis limited the spontaneity of social interactions and some participants felt as if they were left out of certain activities participants felt that they had to make more pragmatic decisions social interactions were limited due to participants physical health constant fatigue or the practicalities of needing to be near a dialysis unit in my personal family we are used to saying oh lets go to the movies or lets go hang out i know i get tired and we cant take that long walk so i either get excluded or the entire trip gets derailed and i feel bad about that my family my husbands side is all from trinidad i would love togobut i cant gothere unless i make allthese arrangements to find a dialysis centre there and since i know i am finally at a decent place here healthwise why would i jeopardise that to go somewhere where the quality of dialysis is poor these responses provided an example of the total impact that dialysis also had on the individual and their entire family strength was often found in faith and family an important theme that emerged was the reliance on faith and family for strength the resolve to live was driven by their spiritual foundation and relationships with their family as previously described there was a strong sense of resignation among some participants however among others there was a firm resilience that was rooted in spirituality one participant stated i gotta go on i got kids i got grandbabies i think that is what keeps me going my grandbabies other responses that demonstrated spirituality as a source of their strength are i try to deal with it and ask the lord to give me strength i went to church and testified it had to be god giving me that strength because i was wondering where am i getting this strength when asked what do people on dialysis need most one respondent stated strong faith my mother and a strong foundation discussion in the united states approximately 500000 people have eskd and are undergoing dialysis this study provided insight into the lived experiences of patients on dialysis and identified several factors that should be considered in developing patientcentered and culturally relevant interventions several themes emerged from this qualitative study that depicted the cognitive and emotional processes that underlie the experience of dialysis overall there was a general sentiment that the onset of dialysis was abrupt and unexpected many participants in this study described hospitalisation as the first time they heard about kidney failure this is consistent with prior studies which demonstrate that among patients admitted to the hospital only half knew they had either stage 4 or 5 kidney disease similar to previous qualitative studies this study also supports the finding that patients often feel illprepared for dialysis the perceived abrupt onset of dialysis calls for interventions that begin earlier in the trajectory of renal disease predialysis education may help to identify patients who are in denial about their risk of dialysis and enable them to develop healthy and adaptive coping strategies research that identifies barriers to referring patients to nephrologists or vascular teams for fistula placement may help patients to prepare for dialysis developing interventions for patients who are in late stages of kidney disease or at imminent risk for dialysis offers new opportunities for education of patients early intervention may delay the onset of dialysis and improve survival intervening in the predialysis phase may also help patients to develop adaptive coping styles which may minimise denial an important aspect of this study was the focus on black and latino patients recruited from a medically underserved and low resource community the experiences of these participants reinforced the tremendous impact of the social determinants of health income level housing employment transportation neighborhood safety social support language fluency culture access to technology are all wellestablished determinants that if left unaddressed can thwart best efforts to improve health outcomes in this study a lack of income unemployment and food insecurity were social determinants that were described as impacting the ability to make healthy lifestyle choices interventions that address the psychosocial needs as well as physical needs are essential another important consideration was the influence of culture participants described challenges to adhering to dietary recommendations that resulted from entrenched cultural practices for example respondents lamented over giving up traditional latin american or west indian dishes participants provided specific examples of meals that they had to avoid such as cheese for patients undergoing dialysis excessive consumption of cheese that is rich in phosphorus can lead to metabolic and bone related abnormalities early involvement of key stakeholders such as patients nutritionists family members and clinicians can be helpful in designing healthy alternatives and culturallytailored advice on how to eat these items in moderation limitations of the study there are limitations of this study that should be considered such as the small sample size recruitment from a single site and a focus on racial and ethnic minority groups the study included 36 participants which reflects the point of data saturation the likelihood that new data would emerge if additional participants were interviewed for this study is low another potential limitation is that this study focused on black and latino patients from one dialysis centre incorporating white patients would be helpful in determining whether there are similar experiences among white patients on dialysis or among diverse populations from different socioeconomic backgrounds a more diverse sample would contribute additional perspectives however for this study the focus on racial and ethnic minorities was intentional as this is the group that is most severely impacted by eskd among patients in our practice notwithstanding the aforementioned limitations the results of this study are timely and align with current trends in health care redesign emerging models of eskd care such as seamless care organizations offer the promise of improving the dialysis experience quality of life and clinical outcomes the assessment of the patient experience will be a metric for fundamentally judging quality of care results from this study can help to delineate specific aspects of programs that matter most to patients as new models of care for patients with eskd are developed this study can provide guidance in selecting the optimal timing for programme implementation in developing key programme components and in identifying key stakeholders that can enhance care for patients implications for practice new models of care should consider including employment programmes that can help patients to develop or identify new skills rather than abandoning prior goals new models of care may need to consider programmes that link patients to careers or provide peer role models on working and remaining engaged in the workforce while on dialysis participants in this study discussed the role of their family and the potential for caregiver burden a review of studies that focused on caregiver interventions found a dearth of studies that specifically addressed the psychosocial needs of caregivers of patients with chronic kidney disease or who are on dialysis there is a need for new models of care to address the psychosocial needs of family members as well as patients to minimise caregiver burden new models of care should also acknowledge the role of spirituality and faith in helping patients to endure the dialysis experience partnering with faithbased institutions may provide additional assistance and support for many patients who rely on their spirituality and faith for strength conclusion this study described the lived experiences of black and latino adults with eskd who were undergoing dialysis experiences were described across a spectrum of cognitive responses that included denial resignation and reliance on faith each experience provides an important lever for creating new patientcentered models of care understanding the totality of experiences of living on dialysis is a preliminary step to improving overall quality of life for patients on dialysis and ultimately to reducing disparities in eskd

background approximately 500000 people in the united states are affected by endstage kidney disease eskd 53 of whom are black or latino eskd significantly impacts psychosocial health and quality of life however few studies address the psychosocial aspects of eskd especially among black and latino adults this study sought to understand the psychosocial context of living with eskd among black and latino adults who reside in a medically underserved community

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introduction since the first loans by muhammad yunus in 1967 microlending has become a global phenomenon of poverty alleviation attracting much academic political and professional attention and commentaries microlending capturing both the original userbased term of microcredit and the business term of microfinance has been praised for its key innovation of replacing individual collateral by contextualized social responsibility for repayment in doing so it is believed to meet the massive credit gap affecting the poor seeking entrepreneurial opportunities while lacking access to bank credit for thus achieving financial inclusion yunus and his legendary grameen bank were awarded the 2006 nobel peace prize however microlending has also been criticized for not genuinely addressing the root causes of poverty and through its evolution into commercial microfinance even providing a means for financial business to make a profit out of poverty perpetuating unequal distributions of wealth and gender besides widespread anecdotal evidence of how microlenders fall into vicious credit traps critical studies suggest that on average the rise and spread of microlending has not made any substantial contribution to wealth creation and more equal wealth distribution from academic work to popular media there is a continuous stream presenting evidence and arguments on the pros and cons of microlending at general as well as detailed level focusing on the multifarious case of microlending this paper investigates what is called a messy object using the notion of an issue trajectory in sharp contrast to consistent and focused objects messy objects respond to multiple problematizations shapeshifting through time and space while prompted and fuelled by a globally circulating concept such as an iconic policy model examples of the latter are science parks regionalindustrial clusters or blockchain what characterizes such messy concepts is that they continuously waver between shapeshifting through local adaptations and working towards common practices of stabilization and coherence an important inspiration for understanding such messy object manifestations stems from the poststructural angle of socialtopological research notably in the domain of philosophy and human geography a specific contribution comes from elaborations of spatial topologies notably by actornetwork theory and its followup yet while this literature provides much insights into the glocal articulations of messy concepts what appears to be missing is a thorough understanding of the dynamic political nature of how messy concepts waver between shapeshifting and stabilizationcoherence to provide such an understanding this paper will elaborate and apply the notion of issue trajectory drawing on the work of latour and marres on material politics an issue trajectory traces the shifts and turns in the development and fate of an object drawing attention to how objects become invested with specific normative powers through the deployment of particular settings and devices by applying the notion of issue trajectory to the messy object of microlending the paper seeks to make three contributions firstly the paper adopts a fully unbounded geographical approach to the spatiality of messy objects exploring the glocal aspects of topological connections we thus acknowledge and meet masseys call to recognise space as the product of interrelations as constituted through interactions from the immensity of the global to the intimately tiny we do so by elaborating different conceptual and empirical kinds of mapping secondly the paper provides an understanding of the dynamic political becoming of messy objects notably of the exemplary case of microlending to do so we advance the theoretical bridge between sociotopological thinking and the dingpolitical notion of issue trajectory in our practical approach this bridge yields a topological canvass used to underpin microlendings conceptual mapping building on these various mappings finally we return to the problem that prompted the writing of our paper namely the divide between the social and commercial orientations of microlending and provide one brief but hopeful suggestion for addressing this divide before we introduce our case and approach a few words on data our account is based on intensive engagement with the phenomenon through processing a vast amount of literature academic professional and media our own data analysis and local fieldwork the account focuses on the period 19802015 as with genealogical analysis the study of objectformation focuses on depth problems that swirl around the heart of who we are in a way that is well grounded and plausible besides an extensive literature review data collection is also based on numerous encounters with experts worldwide complementary ethnographic work has been carried out to zoom in onto nodal cases not covered here microlendings issue trajectory the bringing to presence of a messy object microlending as introduced above entails a practice in which small loans are issued to lenders lacking collateral such practices helping the poor have existed for centuries for instance as loans to young entrepreneurs in the 18 th and 19 th century across europe or in the form of small farmer credit in the 1950s and 1960s yunus revived the practice through the concept of communitybased social collateral implemented by grameen bank in a rural area in bangladesh in the 1980s the initial success paved the way for decades of global proliferation notably via global development agencies and charity networks and prompted by prominent figures such as bill and hillary clinton major events were the launch of the global microcredit summit campaigns in 1997 and the spread of grameen replica projects outside asia an important role in spreading the message was played by a us grassroots advocacy organization results which already in the 1980s supported local microcredit trials consequently results prompted the reagan administration to pass microenterprise poverty lending legislation massive exposure resulted when cbs 60 minutes program broadcast a documentary on grameen in 1990 global reach was achieved consequently through mounting interest from core organizations in development aid particularly ifad the ford foundation usaid and the un in general the microcredit story thus reached out to sites far beyond its asian cradle including the developed world this proliferation strongly affected microlendings problematization through its repetitive implementation and wide circulation the original problematization widened to broader issues of boosting entrepreneurship and sustaining endogenous rural development it also took on global ambitions regarding poverty reduction community development and because of the predominance of female clients gender equality without resorting to redistributional subsidies throughout the 1980s its rootedness in social development shaped microlending as a more or less coherent object albeit one with increasing flexibility or fluidity in its spreading local manifestations this changed in the 1990s when microlending started to appeal strongly to financial organizations and businesses the latter embraced a new problematization namely whether microlending could become a standard banking practice for the poor could microlending turn into new commercial business models enrolling in mass lesswealthy customers previously deemed unsuitable for banking hence microlending became subject to financialization advancing its problematization into two directions first the original socioeconomic ambitions were juxtaposed with commercial goals with a stronger focus on business interests and gains second financialization called for more consistency at the global level through a more uniform calculative practice organizations such as the world bank took farreaching initiatives to standardize definitions rules and practices of what now became labelled as microfinance because ngo and charitybased practices of microcredit also endured including calls for flexibility the result was an increasingly diverse microlending landscape indeed an exploration of the literature on microlending reveals a wide variety of definitions goals actors strategies effects actors over many locations with this diversity microlending turned into a much messier object with a growing and increasingly dominant commercial orientation the result was a divergence in problematization between a social and commercial orientation and even a mounting gap between what microlending initiatives were doing in practice and which concerns they were expected to meet we will describe this divergence as a problematization gap this gap coincided with another divergence in microlendings issue trajectory namely between the opposing tendencies towards standardization and flexibilization these two divergences constitute two empirically grounded dimensions which will be used to plot microlendings issue trajectory as will be discussed in the sections below and concluded at the end mutable mobile topological dimensions to further study microlendings issue trajectory we develop a topological lens drawing on various relational perspectives namely ant postant and latours notion of dingpolitik the aim is not a theoretical synthesis but to sharpen our concepts and tools to map and trace the becoming and proliferation of microlending as a highly messy and contentious issue while topological thinking originates from modern mathematics and philosophy it has obtained the status of the ultimate engine of relationalism in social and cultural studies like genealogy this starts with the question of the becoming of the present as discussed for microlending in the previous section how does an issue acquire global significance reach and impact how does this development shape diverse practices realities and subjectivities these fundamental questions have been addressed in profound and creative ways from a historical perspective notably through the work of great scholars such as braudel foucault deleuze and guattari foucault in particular has played a pivotal role in providing a temporal understanding of the contingency and plurality of the unfolding of society yet while such historical perspectives include geographical details as factual markers a profounder relational geographical understanding warrants a deepening of topological thinking in a nutshell such thinking critically assesses the becoming of issues through the circulation and encounter of practices through time and space strengthening critical genealogical research through geography such a geographical orientation to genealogical work means that we go beyond geographical markers such as place territory scale and networks instead we take on board the inherent spatial relationality and contextuality of each issue in line with the work of law and blok on situated spatialities and globalities in terms of policy mobility this poses the challenge of making sense of fastmoving best practices without losing sight of prosaic practice in geography a major contribution comes from doreen massey in her landmark publication for space massey calls space a sphere of the possibility based on contemporaneous plurality in such a sphere there are always connections yet to be made juxtapositions yet to flower into interaction relations which may or may not be accomplished in masseys rich vocabulary the worlds coexisting heterogeneity produces a throwntogetherness of space giving rise to significant encounters and problematizations that is through our bodily encounters with other bodies in places and across space we sense and give shape to challenges drives and issues in more abstract terms hence issues are relationally constituted through the influx translation and alignment of entities and tendencies drawn from multiple places through a variety of sociospatial practices investing issues with capacities meanings values and normativities how do we trace and map spatial topologies and their role in issue trajectories that basically comes down to exploring the connectivities and associations between entities through which issues become and proliferate here we build on ants foundational thinking in terms of mutability and mobility that thinking is rooted in latours seminal work on immutablemobiles in the development of modern technocratic societies through the proliferation of practices such as classification scripting measuring filing and tooling here we define mutability and mobility as follows • mobility refers to the capacity of entities to associate through inscriptions intermediaries spokespersons etc this requires entities to adopt a semiotic form and engage in moments of translation mobility hence makes objects perform and coconstitute other objects at a distance • immobility in turn refers to moments of material throwntogetherness or conjuncture in which entities are brought to present through folding rather than associating importantly such a throwntogetherness provides critical space for novel problematization objects and spaces which are fully exhausted by associations as argued eloquently by latour would only suffocate topological immobility and folding cultivate vital sites of action creativity and new problematization • mutability refers to the capacity of entities to mutate their topological connections or spherical relations in moments of translation mutability thus stands for reaching out and adapting to different sites and for attuning to other problematizations • immutability finally implies a fixity in spherical relations immutability stands for fixity stability and continuity due to these topological characteristics immutability helps to bring an object to presence unchanged in moments of translation as well as to maintain separation in doing so immutability fuels both order and creativity in line with latours focus on the topological moment of the immutablemobile postant work has identified and studied three further topological moments mutablemobiles mutableimmobiles and immutableimmobiles our emphasis on issue trajectory however means that we prefer to work with mutabilitymobility as crosscutting dimensions rather than archetypical moments chiming with latours emphasis on translation as movement using this twodimensional approach the next section will connect this topological thinking with the concept of dingpolitik and its typology of political modalities dingpolitik the political as latour has fiercely and repeatedly argued revolves around the way issues confront and mess with our collectives the political turns around questions issues stakes thingsin the sense of res publica the public thingwhose surprising consequences leave those who would rather hear nothing about them all mixed up hence issues are political based on problematizations and issue trajectories subject to dingpolitik ding stands here for a gathering or assemblage infused by the weirdwired materiality of our world along a trajectory dingpolitik assumes different situational moments or modalities acquiring political sense and meaning politics is not a site or activity accordingly but what qualifies a type of situation as an act of politicization and political practice latour tentatively identifies five such moments of political practice 1 associational politics and the building of new cosmograms 2 the confrontation of different publics 3 state politics 4 deliberative politics and 5 governmentality importantly as emphasized by blok these five moments should be seen as an openended set of modalities for different sociomaterial worlds rather than a wellordered sequence of contestation and stabilization rather than stages these five moments present markers for the mapping and tracing of an issue trajectory at startup issue trajectories are prompted by a primary mattersofconcern after which trajectories can jump between and swirl along different modalities so the crux of the approach is not the typology or path but the way it helps to trace and follow concrete issue trajectories with all their jumps and swirls dingpolitik accordingly draws our attention to concrete material politics in which issues and modalities should primarily speak for themselves and convey their own specific senses and meanings to enable this and start our investigation we project these dingpolitical modalities onto our twodimensional topological canvass explained before in theoretical terms this connection serves to further ground the relational sociomaterial within a dingpolitical perspective or to turn it around this connection may help to counter the accusation that ant approaches poorly engage with criticalpolitical thinking repeating the warning that issue trajectories do not follow simple paths along set moments we will now discuss each in turn throwntogetherness our conceptual journey starts with the prompting of an issue in particular sites of sociomaterial encounter or throwntogetherness such encounter prompts the sense and articulation of mattersofconcern shaping a first site and gathering of problematization in our case the story starts with the awareness of a community debt problem in some indian villages and their village bank in the words of latour such gathering entails new associations and cosmograms forming aspirational and generative sets of relations between human and nonhuman entities and new forms of agency crucially while gathering practices inevitably involve many moments of circulation for instance of emotions ideas and resources what emerges and performs as matterofconcern is not yet topologically mobile or mutable in line with masseys vivid description of throwntogetherness this is a moment of presence through lived existential encounter issues breed in their microcosmical fold or womb of which topologically speaking the spherical relations are momentarily fixed it is this very fixity which engenders and incubates an issue how does an issue trajectory unfold through which topological moments how does an issue evolve beyond throwntogetherness how does it embark on new associations bringing itself to presence elsewhere while there are no set paths two basic directions can be distinguished the first path has arguably been the main theme of ant an issues problematization can be structured through existing social economic political and scientific frames turning into manageable mattersoffact issues thus transform in wellidentified paths with science as core arbiter as detailed by callon the main challenge hence is to become topologically mobile enrolling and mobilizing actors through the hard work of creating mediators and intermediaries this paves the road to governmentality discussed further below the second trajectory is more open and explorative in line with latours indicative sequence of dingpolitical moments before turning mobile it is important for an issue to bring itself to presence to new audiences and publics thus creating literal locations of truth creating publics so issues become political by meeting and shaping different publics in latours words this happens w henever an issue generates a concerned and unsettled public for our case study the exposure of grameens success to the world of development aid and the wider world presents a key illustration topologically such an encounter entails a moment of communication in the basic sense of making contact whether through interest irritation perturbance or simply awareness it is not about building a relation or association topologically the moment can be described as mutableimmobile following postant thinking the way an issue develops through mutableimmobile moments can be described through notions of fire and flickering law and singleton speak of an object that jumps creatively destructively and more or less unpredictably from location to location it is an object in the form of a dancing and dangerous pattern of discontinuous displacements between locations that are other to each other an important counterpart of such jumpy unsettled presence is flickering absence in a topological perspective what becomes present and how very much hinges on what remains absent or what is othered othering constitutes an issue by defining what it is not by silencing what could be unsettling and by hiding much of an issues past controversies sensitivities and missing entities othering silencing and hiding in turn always require a certain presence of ordering and separation and can thus never be absolute absences remain flickering through which an issue lives in and through the juxtaposition of uncontrollable and generative othernesses where law and singleton observe flickering in the multiple enactments of alcohol liver disease by patients gps and hospitals we will see such flickering and the important role of generative othernesses in the struggle between the commercial and socioeconomic approach to microlending dingpolitical flickering takes the form of enflaming and spreading plural ideas through public arenas and the media focusing attention and interest in modern societies mattersofconcern become public matters through means of agitation and contagion with a crucial role of public debate and the media in our age the jumpiness of issues and flickering of absences is manifested in the development and use social media and other strong means of allowing swift crossindividual and impactful presence indeed one could argue that modern communication has increased the openness and vulnerability to more distant othernesses while enabling local disconnections a vivid illustration is the sight of a group of colocated family members and friends all immersed in their smartphones as callon contends this antnotion that the local is an achievement in which a place is localised by other places and accepts localisation itself the call for dingpolitik thus includes a deep understanding of its material and topological grounding in our case study we will follow our issue as constantly evolving patterns of presences and absences with shifting associations and allies settled politics shaping constituencies and governance we now move from a flickering to a modern organized world meeting ideals and practices of deliberative democracy under the latter publics turn from concerned and agitated to more settled visible and expanding concerns narrow down to issues featuring at organized political stages with stakeholders spokespersons rules procedures conventions paper trails etc political practice becomes enacted in deliberative assemblies that frame and order the plurality of voices and the multiplicity of issues through framing and ordering presences become more articulated and performative while the flickering of absences is smothered if successful addressing issues takes the form of puzzlesolving through seemingly ordered and responsible infrastructures of communication and governance two political modalities stand out here namely constituencies formed through and around deliberative assemblies and governance as an orderly metaassembly of different constituencies sharing a common neutral language topologically assemblies and governance require an issue to adopt a form that is mobile and can be enacted in different sites while still presenting and circulating as an apparent whole governance practices tame and domesticate issues while keeping them mutable this can occur for instance through consensual expressions open scripting and flexible tooling the quintessential example of such a mutablemobile entity is de laets and mol bushpump adapted to and materializing in different zimbabwean villages in our case such governance will become manifest through the glocal networks and organizations shaping and dispersing microlending ideas and practices as we will detail later what made microlending whole as a mutablemobile includes a series of macroscopic practices such as organizational membership cataloguing and authoritative storytelling underpinning a shared identity however settling into assemblies and governance always runs the danger of turning into as latour describes it a sad dream absences extinguished by framing and ordering may flicker again due to impactful events and revelations governance practices are both inclusive and exclusive if sentiments of exclusion and discontent mount publics may become unsettled and antagonistic what appeared topologically mobile may then turn immobile again reigniting more fundamental struggles for publics and ordering an unruly mob may even try to disturb and occupy an assembly site including the seats of parliament our case will tell of struggles and occupations triggered by severe human and social despair resulting from microlendings financialization a critical question then is to what extent such frictions open the door to generative othernesses mentioned above governmentality besides inducing mobility modern drives to order and control also strive for immutability in latours words this final modality displaces the problematization and handling of issues to the daily routine of administration and management the latter address issues through the rationalframes of economics managerial politics and science and the ordered wheels of bureaucracy as captured by foucaults notion of governmentality wherever possible modern order relies on mathematical metaphors as channels to a transcendental unity picked up and used to represent the world variegated mattersofconcern are thus narrowed to fully domesticated and regimented mattersoffact circulating and enacting an issue through a highly standardized framing of subjects and objects the major concern becomes efficiency defined through single calculated truth enacting an ordered coherent and as far as possible formalized reality indeed as latour argues the basic problem with mattersoffact is not a lack of truth but their partiality matters of fact are only very partial and very polemical very political renderings of mattersofconcern and only a subset of what could also be called states of affairs topologically this presents the immutablemobile moment immutability ensures full equivalence of all relevant sites and contexts mobility enables full transparency across sites together immutability and mobility support full capacity to scale and calculation consequently the transformation to governmentality is deeply doublefaced on the one hand as we will also witness in the proliferation of microlending the scaling and calculation capacities stemming from immutablemobility can be empowering and highly productive it allows practices to gain high efficiency and reach establishing general equivalence between local microlending practices enables smoother associations with other circuits like global development aid and financial capital with a regimented immutablemobile presence an issue can mobilize stakeholders and gain support with more intensity and clout on the other hand the closure and partiality of governmentality runs a major risk of creating massive problematization gaps by its very nature governmentality severs links to audiences deliberations generative othernesses and lived realities outside of its own frame taken to its extreme technocratic closure may lead to a situation in which axiomatic practices of politicization and bureaucratization define how issues are discovered identified and fixed cut loose from other realities and sites mattersoffact may become overwhelmingly selfreferential such as the selfpropelling growth of the financial sector when confronted with pressing problematization gaps a common response is to retune and recalibrate methods of defining scripting and measuring creating better calculations another response is to turn to governance by developing more flexible scripts and tools to accommodate variations in contexts the real challenge for meeting problematization gaps however is to reach out to wider publics that is to see problematization truly from a perspective of those affected we will return to the latter challenge in the conclusion with this issuebased topological lens the remainder of the paper will focus on three critical directions in microlendings issue trajectory financialization through topdown imposition of topological mobility the fight for more openness and flexibility meeting the widening problematization gap and a return to immobility in attempts to reroot microlending practices in their local settings imposing mobility financialization and standardization as introduced in section two microlending underwent massive change through a process of global financialization entering the context of global finance came with new impositions notably scaling and standardization through the adoption of standard banking technology and routines to control costs microfinance institutions must streamline and routinize the exchange of money between staff and clients microfinance must be massproduced besides the world bank standards originated from the compliance and rating agencies in charge of controlling the financial sector across the globe were applied to local microlending practices now renamed as microfinance institutions or mfis particularly influential for creating standardized microfinance rules has been the publication and extensive circulation of the pink book by the consultative group to assist the poor an agency established by the world bank in 1995 after a first publication in 1995 a revised version of the pink book in 2006 included standardized guidelines and best practices of microfinance the book stated for instance that interest rate ceilings hurt poor people by making it harder for them to get credit and recommended that in cases where nonbank institutions such as ngos need explicit legal authorization to lend encourage regulatory changes that allow creditonly institutions to lend without prudential licenses or supervision besides the influx of many commercial parties cgaps guidance even induced ngos to transform their legal status into financial institutions an illustration is the way cgap showcased the transformation of the nonprofit prodem into the commercial bancosol mfi in bolivia moreover in order to create transparency and a factual basis of policymaking unctad and the world bank set up a global database mixmarket to code and count mfi activity worldwide this came with principal criteria and protocols detailing how and which to collect store represent and analyse microfinance data since its launch in 2002 mixmarket has played a key role in creating oversight which has been mined for dozens of microfinance studies worldwide likewise microfinance rating agencies appeared and adapted standard and poors evaluation methods whilst standard ratios and benchmarks were developed to measure performance through comparable widely accepted and costeffective indicators the arguments and rules for central microfinance data collection storage and research rules serve to frame the basic mechanisms of lending risk management and profitmaking mader writes that the financialization of microfinance is so dominant that it is presented as being part of the transnational financial market exerting normative power in favour of certain ruleregimes such as liberalized banking regulations rather than a development tool channelling investmentoriented development aid microfinance became a practice capable of generating financial yields for investors creating profit out of poverty in topological terms financialization imposed a strong drive to the use of immutablemobile devices and connectivities however standardization also hit a barrier because of the small size and sitedependent nature of the loans global compliance continued to warrant national and local adaptation of standardized practices and customization of rules and norms so given major differences between local contexts of microlending it proved impossible to turn the rules and calculative practice into detailed global scripts the trend towards financialization accordingly resulted in many local versions an illustration for the practical need for customized practices comes from canales if the policies are too rigid we need to be able to provide our clients with different options we need to find alternative solutions i cant just go directly against a policy but i can combine different policies creatively and present my client with options to solve her problem what resulted hence was a complex topdown system of global orchestration and circulation of financial practices of standardization and scaling supported by massive investments matched by continual adaptation of local practices and forms of microlending this mutability however was primarily technical and instrumental it was not an expression of political and policy autonomy in topological terms mutability served to prevent financializing microlending practices from rupturing while travelling giving different sites of microlending a single kind of presence that could be expressed registered counted and amassed in databases such as mixmarket to use the terminology of lépinay mutability endows an issue like microlending with liquidity enabling its circulation through the mainstream circuits of economic development and support in other circuits however a different response emerged as discussed below calling for more mutability socioeconomic versus financial concerns due to financialization after 2000 microlendings goal of profitmaking overtook its goal of poverty alleviation one of the most prominent signals was the extremely profitable stock offering of the mexican mfi compartamos in 2007 featuring in the international media although this had been preceded by other initial public offerings for instance the bri ipo and the equity bank ipo the mexican ipo caught global attention due to its intensity and the size of its profits and triggered an overwhelming interest from financiers in microfinance microfinance thus became mobilized as an asset class offering an attractive global opportunity for portfolio diversification accordingly what had started as financialization of microcredit advanced through growing commercialization of microfinance motivated and justified by its high and safe levels of return because of its decentralized nature and relatively strong commitment to repayment the risk of defaults was seen as slow and the value of expected recoveries as good turning microfinance into an attractive opportunity for portfolio growth and diversification in time the growing schism between the poverty reduction approach associated with development aid and the commercial profitseeking approach gave rise to a mounting problematization gap around 2000 the problematization gap was framed as a mission drift in which microlending institutions were scalingup their business and increasingly targeted the betteroff poor instead of the very poor serious doubts emerged about the extent microlending practices would be able to truly meet the doublebottom line of microlendings socioeconomic and financial ambitions turning increasingly financial and commercial microlending was accused of merely embracing a neoliberal doctrine to create profit for already welloff investors it was questioned which place the pursuit of explicit development goals had in the context of increasing specialized commercial microfinance following this line of thinking the problematization gap became framed in terms of a standoff between a commercially oriented washington consensus on microlending led by the world bank and an opposing socially oriented bangladesh consensus on microlending led by grameen bank the director of asa one of the biggest microlending institutions in bangladesh shared during an interview in 2004 the bangladesh model has grassroots organizations that serve the poor and that cannot accept the types of commercialization that are being imposed in topdown fashion by cgap they think in profits in their banking model we think of poverty in our ngo model topologically what had become the undercurrent of poverty reduction through socioeconomic development thus continued to flicker as a generative otherness however how to address the gap with commercialization proved difficult for the advocates of the bangladesh model a dominant strategy was to extend rather than counter the financial sides use of calculative practices for a long time most mfis assess their socioeconomic performance through the measures in the socalled yarons framework equating socioeconomic performance with outreach to be sure the microcredit model has been celebrated for the extent of outreach achieved as illustrated by the goal of reaching 100 million poor people with credit for selfemployment by the year 2005 set during the first microcredit summit campaign in 1997 this focus was later heavily criticized for the fact that reaching people with microcredit says little about the effect that it has on poverty so the call was on for more precise socioeconomic impact indicators however socioeconomic performance assessments proved incapable of achieving the same clarity consistency and level of acceptance as financial performance assessments in 2002 in response the social performance indicators initiative was launched the initiative was administered by ceris a platform of francebased microlending support organizations under coordination of cgap three years later a social performance task force was created motivated by the argidius foundation cgap and the ford foundation sptf has served as a forum for defining socioeconomic performance creating a common framework on the basis of social performance standards as a result alongside commercial indicators a number of socioeconomic indicators were finetuned and included in the performance calculations these calculative practices thus brought social norms more to presence in the financialized context of microlending what is more evaluating socioeconomic performance of microlending has been taken seriously in microlending research and ratings however although this shift prompted some changes in more specific regulatory contexts it has not produced a coherent integrative working practice of microlending while some operational consensus was reached in the form of financial and socioeconomic calculative practices through extending their mutability no consensus emerged on either the concept of microlending or on overall the values and ambitions the problematization gap remained battling for immobility despair and hope in many places the enrolment and mobilization of microlending projects through homogenizing financial practices resulted in major tensions and even outright failure hitting at the heart of local communities tensions and failure resulted from acceleration of capital injections and lending resulting in excessive rises in client numbers and loan sizes prompted by the normalization and standardization scripts of commercializing microfinance interestingly enough ample warnings and facts of overindebtedness of microfinance clients surfaced but these were explained away by blaming the sector through qualifications such as oversaturation of the market and unsustainable finance rather than to the accelerating financial practices themselves in time however failures turned into spiralling indebtedness and default bringing to presence what the regulatory scripts of commercializing microfinance should have prevented the primary response to this was to actually reinforce commercial standardization and secure more liquidity for the sector by encouraging linkages between mfis and banks other responses included the transformation of ngomfis into commercial regulated entities and the improvement of database transparency failure was attributed to lenders residual dependence on development aid and subsidies prompting further consolidation of microlending through tightly controlled calculative practices however such a response proved more difficult for another kind of flickering namely social contestation and protest the 2000s witnessed waves of protests and demonstrations against financialized microlending practices across the world demonstrations materialized for instance in bolivia in 2000 in morocco in 2007 in pakistan and nicaragua in 2008 and in andhra pradesh india in 2010 through hunger strikes payback strikes various small but vocal demonstrations and ultimately the hostage taking of bank staff in bolivia in 2001 demands were voiced of debt relief grace periods longer loan terms and reduced interest rates most dramatically 2010 saw were various reports of suicides related to overindebtedness induced by microcredit in india more than failure these lived realities of microlending could not be simply regulated away rather these confronting encounters and realities resulted in attempts to repoliticize microlending that is to return to the basic mattersofconcern bastiaensen et al state it is crucial that the debate about microfinance and microfinance itself be repoliticized this call reestablished a link with yunus original emphasis on social mobilization and the building of alliances among the poor to create counterestablishment forces yunus and jolis considered microcredit as part of a localized system of democracy and joined development strongly territorialized democracy allows the poor to take advantage of their greatest asset their large numbers to do so they must be actively organized for the 1991 elections i ensured that 100 percent of all adult grameen family members were registered to vote i also recommended that each grameen center collectively decide which candidate the members would support and that they parade to the voting booths together as a voting bloc in 1992 some four hundred grameen borrowers were elected to union councils and in 1996 more women voted in the national election than men which helped to nearly wipe a political party that had taken positions against womens rights out of the parliament in 1997 many grameen members were elected to local offices constituting 6 percent of the total elected representatives in all the local bodies in the country however in view of the advanced globalized and financialized state of microlending repolitization warrants more than a return to a more locally rooted lending practice it also requires a fundamental debate about the roots and publics of the movement itself already in 2001 that was an issue raised by imran matin a major ngoplayer in the field some in washington dc have the power to say what is appropriate and what is not they insist that one has to first build financial institutions and then do social development that is not our history we did not start out as financial institutions more recently a broader set of debates has emerged exploring the material basis of microlending and calling for alternative foundations prompted by debates on sustainability a suggestion is to extend commercial and socioeconomic norms with an environmental pillar to thus shaping a kind of green microfinance other experiments may stem from a growing interest in rentfree islamic microlending practices the first connections that are made between the circular economy and microlending in popular media or the proposals for a basic income such moves are backed by the idea that microlending through its very nature is less susceptible to speculative financial wizardry in the words of yunus the simple reason is because we are rooted to the real economywe are not paperbased paperchasing banking when we give a loan of 100 behind the 100 there are chickens there are cows it is not something imaginary a problem however is that these debates tend to focus on the direct motives and logics of microlending practices rather the more fundamental question of how underlying mattersofconcern are presented to which publics for which constituencies and through what kinds of dialogues in hindsight despite yunus inspiring words regarding democracy this has arguably been an omission even in microlendings early days even then as described in section two the phenomenon became quickly captured by leading organizations and global celebs in other words the pressing question is to what extent current calls and moves provide enough clout for an open and engaging modality of dingpolitik to really affect microlendings issue trajectory what is hopeful though is that microlending continues to confront our deeply financialized economic practices with fundamental grounded questions of development and territorialization three plots to conclude since the late 1960s microlending has undergone an eventful jumpy and swirling issue trajectory this paper has explored that trajectory using topological mapping inspired by ant thinking latours notion of dingpolitik and the rich literature on microlending our aim here thus was threefold namely first to map a genuinely glocal issue trajectory based on second an approach bridging topology and dingpolitik considering third prospects for change in this conclusion each aim will meet a final plot our first plot tracks microlendings issue trajectory along two tensions namely standardization versus flexibilization and socioeconomic versus commercial orientation this plot marks what in our view are the key moments in which microlendings glocal events through their topological makeup and impact shaping its issue trajectory the first tension stems from the fundamental drives towards standardized practices aiming at a globally consistent object through fixity and calculation and towards flexibilization aiming at coherence through shared norms goals and debate in the microlending case this critically revolves around the process of and responses against financialization the second tension addresses the way the issue trajectory has forked between social and commercial goals and how that has given rise to an increasingly palpable problematization gap using these two axes figure 2 shows how microlendings issue trajectory runs from grameens original sitespecific socioeconomic practices via the global leveraging and homogenization of financial practices and countermovements focusing on social aims to groundswells of reviving diverse social practices although our account only provides a digest of the multitude of practices involved it indicates how the hard and generative work within mfis worldwide including calls for flexibility and dialogue meets strenuous efforts to develop and impose frames and devices for stable circulation and scaling however abridged figure 2 gives us a window on to repeat massey microlendings sphere of the possibility based on contemporaneous plurality the second plot charts key parts of the issue trajectory onto the topological canvass of figure 1 above it thus marks core moments of mutable mobility placing them in the perspective of latours dingpolitical modalities based on our review this yields a threefold trajectory the first arrow describes the dominant transition from the grameens success and rapid global proliferation to financialization under the topdown orchestration of the world bank ngos and other global players the main aim here was to capture microlending in a neoliberal technocratic regime of capital accumulation moving swiftly from problematization to governmentality yet because of the nature of microlending successful propagation and amassing of calculative practices warranted a certain level of mutability pushing the trajectory towards mutablemobile the second arrow reflects the response to the problematization gap prompted by financialization extending mutability towards socioeconomic concerns as explained in the section calling for more mutability socioeconomic versus financial concerns this move was somewhat halfhearted rather than breaking with the reliance on calculative practices an attempt was made to widen their scope the third arrow presents the call for repoliticization revisiting the mattersofconcerns including a search for publics and constituencies the section microlendings issue trajectory the bringing to presence of a messy object and battling for immobility despair and hope provided a range of established and upcoming concerns which may further fuel the debate entrepreneurship gender greening wealth distribution islamic banking etc what is important is the question of how this politicization takes shape also important is that the trajectory should go beyond publicsconstituencies and latours sad dream of governance and very partial governmentality the challenge hence is to shape scripts and devices in such a manner that they respect and can reopen underlying dialogues encounters and generative othernesses what to imagine here is the subject of our final plot our third plot meeting the papers third aim builds on the third arrow in figure 3 our exploration suggests that dingpolitik may incite a trajectory of hope through its grounding in lived materiality and its calls for issuespecific dialogue publics and political practices from a critical geographical perspective this also meets masseys closing words to embrace space as the radical contemporaneity of an ongoing multiplicity of others human and nonhuman and the ongoing and everspecific project of the practices through which that sociability is to be configured to root microlending practices it may be useful to conceive mfis including the circuits in which they are embedded as territorial projects as so well illustrated by grameens early success this territorialization presents the key context for politicization for debating mattersofconcern engaging with publics developing financial practices etc however such territorialization is essentially glocal involving complex infrastructures inscribing a myriad of political and moral capacities as well as all kinds of organizational and economic interests so what could such a territorial project entail we imagine a scenario drawing from a foundational aspect of microlending namely the practice of social collateral underwriting individual credit to counter the perversion and despair caused by financialized microlending and to reorient mfis to communities socioeconomic ambitions microlending as a territorial project should start from a political debate on the nexus between trust and credit and the practice of social collateral to pursue this issue the debate can benefit from other forms of communitybased credit like credit unions and circular and complementary currencies in which themes of trust collateral and material practices have received ample attention consequently mobilizing other publics and organizations may help to develop more socially oriented financial practices with sufficient flexibility and capacity for learning and adaptation with this final plot we hope to have further illustrated the significance of topological and dingpolitical thinking about messy objects playing such a multifarious role in meeting key societal challenges declaration of conflicting interests the author declared no potential conflicts of interest with respect to the research authorship andor publication of this article arnoud lagendijk holds the chair of economic geography at radboud university nijmegen the netherlands and participates in a range of projects addressing innovation and diffusion of regional practices in the field of economic development and mobility kim simons is currently working at the province of utrecht the netherlands coordinating policy and projects on the circular economy before entering the province she was a researcher on microfinance at radboud university nijmegen

microlending microcredit and microcredit presents a complex glocal phenomenon meeting social concerns poverty and community development versus commercial interests manifesting a myriad of practices and trends worldwide this paper elaborates the concept of issue trajectory enhanced by topological thinking to understand the becoming of microlending and to consider possibilities for change the issue trajectory maps microlendings proliferation and divergence between 1980 and 2015 using an analytical lens drawing on a combination of the topological dimensions of mutability and mobility and latours dingpolitik using this lens the study reveals how the continual grounding and proliferation of practices of microlending meet global drives towards standardization and financialization and how this results in problematization gaps between social and commercial aims through adaptation as well as confrontation these gaps bend microlendings issue trajectory towards new political modalities and publics and potentially new forms of territorialization

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introduction the presence of behavior problems during childhood and adolescence is currently a phenomenon causing great concern these problematic behaviors frequently lead to antisocial andor delinquent behaviors with negative consequences for the development and psychosocial adjustment of the adolescent in spite of the fact that delinquent behavior includes a large variability of manifestations course and prognosis there is a consensus among authors about a series of common traits these behaviors are a threat to the integrity of others they infringe social and juridical norms they are notably frequent and intense and they are a risk for development and they interfere especially in the individuals processes of adaptation thus taking into account the complexity of the construct we could refer to a continuum that begins with problem behaviors passing through antisocial behavior and ending with delinquent behaviors of greater severity and social scope one of the topics that has received the most attention in the study of delinquent behavior is the analysis of the factors that intervene in the origin and maintenance of this type of attitudinalbehavioral repertories the more traditional hypotheses point toward certain personal variables as the main triggers of delinquent behavior in the same vein are the notable contributions like that of patrick et al which refer to two personality dimensions that could be directly related to the presence of severe behavior problems and participation in delinquent actions the presence of psychopathic personality traits has also been indicated as one of the triggering factors of severe patterns of antisocialdelinquent behavior in children and adolescents in other cases sensation seeking is proposed as one of the characteristic traits of adolescent personality that along with the lack of control of impulses favors the subjects involvement in risk behaviors according to harden et al this adolescent tendency to seek sensations is mainly due to changes in personality explained by genetic factors thus changes in sensation seeking would partially explain a greater proclivity to delinquency during adolescence in spite of studies that separately analyze the factors involved in the origin of delinquent behavior the current tendency is based on a multidimensional and dynamic approach in which the proposed variables must be considered as part of a compendium and in continuous interaction thus we found works analyzing the relation between emotional intelligence and aggressiveness behavior problems and antisocial and delinquent behaviors on the other hand authors like van der graaff et al point to the moderating role of empathy in the perception of parents support and their childrens performing delinquent actions these authors found that adolescents with lower empathy had a more negative perception of the support received from their parents and they presented a greater number of delinquent behaviors parenting styles and the characteristics of family relations may be the elements that have received the most attention in the analysis of problem behaviors either as risk or protection factors in any case the efficacy of the interventions reveals the importance of family factors as a cause of andor solution to this problem concerning the family context report that childrens exposure to episodes of domestic violence and frequent conflicts between the parents is related to the onset of aggressive and delinquent behavior in adolescence likewise other noteworthy works on attachment and delinquent behavior indicate that the establishment of stronger ties with the parents predicts a lower risk of delinquent behavior in adolescence regardless of the degree of exposure to violent episodes during childhood in other cases interest is drawn to the study of the effects of parental control and the use of discipline as key aspects in the origin and maintenance of delinquent behaviors in adolescents in the school setting in addition to the presence of delinquent behaviors the increasing frequency of academic failure is another concern many authors coincide in relating involvement in delinquent actions to low academic performance leading to failure and school dropout in this regard the selfconcept as a correlation of social adaptation in adolescence plays an essential role jiménez et al found that a positive academic selfconcept fulfills a protector function against the development of delinquent behaviors likewise authors like nakamoto and schwartz state that involvement in violent episodes will have a negative effect on academic performance ma et al note that aggressors perceive their competences as being more impaired and therefore they obtain worse academic results on the other hand the expectations of selfefficacy and the academic goals give rise motivational profiles and may be detrimental to academic performance in the cases involving aggressors problems relating to the peer group can derive in academic difficulties the development of violent interactions in childhood or the amplification of behavior problems in adolescence at this point especially during adolescence the processes of peer influence determine psychosocial adjustment and the acquisition of certain interpersonal values that will guide relations with the peer group according to knecht et al adolescents select other group members as friends as a function of the level of similarity in interpersonal values therefore processes of influence and adaptation of antisocialdelinquent behavior among its members will take place in the peer group in addition both in the family context and in the peer group the acquisition of certain interpersonal valuespositively or negatively related to delinquent behavioris implied an aspect that the present study attempts to examine recently others proposals show the predictive value of social support in the emotional intelligence of adolescents on the other hand the time dedicated by adolescents to the use of internet and inappropriate videogames has been related to the acquisition and change in the values of youth and may be associated with a higher probability of delinquent activities this is why more attention has been paid in recent years to the variables that make the onset of antisocial behaviors less likely or that attenuate their manifestations after they have emerged thus attitudes and values such as social sensitivity prosocial leadership or safety in interpersonal relations have been related to competence and adequate social adaptation in adolescents lastly in order to provide greater clarity in this regard we present this work which will attempt on the one hand to analyze the influence of academic performance on delinquent behaviors and interpersonal values on the other hand it also analyzes the relation between high or low scores in interpersonal values and the presence of delinquent behaviors in secondary education students lastly we wish to analyze the degree to which interpersonal values fulfill a protective function against delinquent behaviors in secondary education as well as the interaction of academic performance with interpersonal values and its impact on the presence of delinquent behaviors materials and methods instruments academic performance this was measured with the items did you ever fail a subject have you ever repeated a course in both cases the response options were yesno interpersonal values questionnaire this 90item instrument has two response options and analyzes six aspects of the individuals relationship with others stimulation conformity recognition independence benevolence and leadership antisocialdelinquent behaviorsquestionnaire this includes a total of 40 items that assess antisocial and delinquent behaviors internal consistency was analyzed by the coefficient kuderrichardson for each of the scales of interpersonal values questionnaire and scale of criminal behavior of antisocialdelinquent behaviors questionnaire in general the internal consistency coefficients obtained for scales in the study sample were high indicating adequate homogeneity among the items of the questionnaires procedure we contacted the headmasters and guidance counselors of the selected schools to present the goals of the study and the instruments to be used therein if they expressed interest in participating we requested their permission and the necessary collaboration to carry out the study this study was exempt from ethical approval because the study did not involve any potential risk for the participants all participants provided written consent we held a meeting with the parents and the principal researchers and after informing the parents we obtained their consent for their children to participate in the study we then scheduled the application of the questionnaires the questionnaires were administered in two 50min sessions with a variable resting time between them separated either by a class and a recess or simply a recess with more than 20 min between sessions the questionnaires were administered collectively in the classroom or in one of the spaces of the school if various classes were grouped together the questionnaires were voluntary and anonymous data analysis for the present study we used a crosssectional descriptive and correlational design in order to determine the relations between interpersonal values and delinquent behaviors as well as the relationship between these two aspects with the subjects academic performance measured as a function of having failed a subject and having repeated a course after the normal distribution of all the siv scales had been determined we identified the criterion to define the thresholds of the sample on these scales thus the total sample of subjects was divided into two groups for each one of the scales students with low scores on stimulation conformity recognition independence benevolence and leadership that is who obtained scores equal to or lower than percentile 25 scores equal to or higher than 14 11 8 13 14 and we used students ttest to analyze the differences between individuals with high and low scores on the siv questionnaire scales between students who hadhad not failed as well as between students who hadhad not repeated a course regarding delinquent behavior to determine the magnitude of the effect size of the significant differences yielded by the ttest we used cohens d index the interpretation of which is d ≤ 050 indicates a small effect size d ≤ 079 indicates a medium effect size and d ≥ 080 indicates a large effect size in order to analyze the predictive capacity of interpersonal values and academic performance on delinquent behaviors we performed binary logistic regression analysis using the forward stepwise regression procedure based on walds statistic thus the six predictor variables and the criterion variable were divided as a function of high and low thresholds maintaining for the predictor variables the one used in the previous test regarding the predictor variables failing and repeating it was not necessary to establish any threshold because the students were grouped as a function of whether or not they had that characteristic to classify the sample according to delinquent behavior we followed the same criterion as with the siv questionnaire dividing the sample into subjects with high and low scores as follows subjects scoring high in delinquent behavior were those who scored equal to or higher than percentile 75 subjects with low scores in delinquent behavior were those who scored equal to or lower than percentile 25 this model allows determining the probability of occurrence of a certain fact or event in the presence one or various predictors using the odds ratio statistic to estimate this probability both in the total sample and in the sample as a function of the variables gender failing and repeating lastly to analyze conjointly the scores of the subgroups derived from the interaction of the predictor variables we carried out a twofactor anova with interaction results delinquent behaviors and interpersonal values as a function of failing and repeating observing the mean scores for delinquent behavior and the different interpersonal values as a function of the variable failing students who had failed a subject presented significantly higher mean scores in delinquent behaviors recognition and leadership with small effect sizes except for delinquent behaviors where the effect was medium on the other hand significantly higher scores were only found in the value benevolence for students who had never failed and again in this case the effect of the variable failing was small when addressing gender we observed that the same results were repeated in the groups of males and females except that for the females no differences were found in the mean score of the value leadership the analysis of the mean scores of interpersonal values and delinquent behaviors as a function of repeatingnot repeating a course revealed significantly higher scores in leadership and delinquent behaviors for repeaters with a small effect for the variable repeating in both cases whereas nonrepeaters presented significantly higher scores in stimulation also with a small effect for the variable repeating the same thing occurred in the analysis as a function of gender in the group of males and females except that in the males no differences in the mean scores of leadership were obtained delinquent behaviors in students with high and low scores in interpersonal values table 3 presents the differences in the presence of delinquent behaviors between students with high and low scores in the diverse siv scales in the total sample as well as according to gender failing and repeating a course for the total sample all the scales presented significant differences except for the value stimulation thus students with high levels of recognition independence and leadership showed significantly higher levels of delinquent behaviors with a small effect size of the values recognition and leadership whereas the effect size of the value independence was medium students with low levels of conformity and benevolence displayed significantly higher levels of delinquent behaviors in both cases with a medium effect size of both values in the analysis as a function of gender we observed that males and females with high levels of independence and leadership both presented significantly higher mean levels of delinquent behaviors with a small effect size in all cases except for the females in the value independence where the effect of delinquent behaviors was medium regarding the variable failing as in the total sample the students who had failed and who presented high levels in recognition independence and leadership also displayed significantly levels higher in antisocial behaviors with a small effect size except for the value independence where the effect was medium in the group of students who did not fail only the value independence had an effect on delinquent behaviors with a medium effect the mean level of delinquent behaviors was statistically higher among students with high levels of independence in the group of students who had failed those with low levels of conformity and benevolence obtained significantly higher mean scores in antisocial behaviors with a medium effect size for both values this same result was observed in the group of students who did not fail but only for the value conformity with a medium effect of this value on delinquent behavior lastly with regard to repeating a course nonrepeaters who scored high on the scales of recognition independence and leadership also obtained significantly higher mean levels of delinquent behaviors with effect sizes of d 040 d 050 and d 055 respectively this effect was also observed for the value independence among repeaters likewise nonrepeaters with low levels of conformity and benevolence presented higher mean levels of delinquent behaviors with a medium effect size for both values this same relation was observed among repeaters between the value benevolence and delinquent behaviors with the same effect size as in the nonrepeaters do interpersonal values predict delinquent behaviors table 4 presents the probability of presenting high levels of delinquent behavior derived from the binary logistic regression in the total sample considering the variables gender failing and repeating the correct percentages of classification ranged between 574 and 698 for recognition and conformity respectively regarding gender for males the correct classification ranged from 577 for the factor leadership to 674 for the factor conformity with regard to the females the correct classification ranged between 716 for independence and 744 for conformity concerning failing the percentages for those who had failed a subject ranged from 622 for leadership to 706 for conformity but recognition did not enter the model in the group of students who had never failed the correct percentages ranged from 803 for independence to 814 for conformity in the analysis of the groups of repeaters and nonrepeaters the levels of correct classification ranged between 64 for recognition and 721 for conformity in the group of repeaters the correct classification ranged from 726 for the factor independence to 696 for the factor benevolence nagelkerkes r 2 ranged between 002 for the females in the factor leadership and 028 for the nonrepeaters in the factor conformity the analysis and interpretation of the or data obtained in total sample indicate that the probability of presenting high levels of delinquent behavior is 458 times higher in students with high independence 334 times higher in students with high leadership 177 times higher in students with high recognition 021 times lower in students with high benevolence and 018 times lower in students with high conformity in the analysis as a function of gender and the variables failing and repeating the probability of presenting high levels of delinquent behavior is 024 011 021 017 and 011 times lower in students with high conformity 007 times higher in students with high recognition 314 745 024 533 408 and 7 times higher in students with high independence 036 016 028 020 and 020 times lower in students with high benevolence and 109 003 282 and 325 times higher in students with high leadership we analyzed the scores obtained in the five factors as a function of both variables by means of a twofactor anova with interaction obtaining a significant interaction only between the factor benevolence and the variable failing f 74 p 001 r 2 013 as shown in figure 1 discussion with regard to the first goal of this study we note that the students who failed and the repeaters present higher means of delinquent behaviors both in males and in females with a medium effect of the variable failing and a small effect for the variable repeating respectively these results are in line with those found by other studies relating low academic performance with delinquent actions not only students who fail but also the repeaters present higher means in the values of recognition as well as in the value of leadership these differences are maintained in the groups of males and females who fail a subject but only for the value recognition with a small effect size on the other hand students who had not failed obtained higher scores in the value benevolence and nonrepeaters in the value stimulation with small effects of both variables failing and repeating respectively whereas in other studies the value leadership is understood as prosocial leadership and is related to competence and social adaptation in adolescents in our study leadership has a negative interpretation in the questionnaire that assesses it because it refers to exerting authority over other people that is a position of control or power therefore it may be appropriate to use another type of instrument that would allow us to measure this value positively in order to analyze the influence of prosocial leadership on adolescents delinquent behavior the results achieved for our second goal reveal that students with high levels of recognition independence and leadership show significantly higher levels of delinquent behaviors regardless of the variables failing and repeating and of gender concerning independence and leadership moreover students with low levels of conformity and benevolence obtained significantly higher levels of delinquent behaviors regardless of the variables failing and repeating that is individuals who like to be acknowledged admired and approved of by others who use their own criteria to decide what they have a right to do who exert authority and power over others who do not follow socially correct or appropriate norms or rules and who are not very generous and do not help othersall these individuals present higher levels of delinquent behaviors lastly with regard to the third goal the probability of presenting a high level of delinquent behavior is greater among students with high independence high leadership high recognition low benevolence and low conformity these five negative predictors should be the target of intervention in order to eliminate delinquent behavior ultimately we note the great importance of the interaction of benevolence and failing which when levels of benevolence are low and the student has failed some subject leads to a considerable increase in delinquent behavior a limitation of this study is the sample which although representative only included students from secondary education a possible goal of future research is to carry out this same study with higher educational levels or in nonregulated studies to determine whether the influence of interpersonal values on delinquent behaviors changes or remains the same therefore although the present study presents some limitations to be taken into account in future studies it can be considered a precursor in a new line of research to clarify the relation between delinquent behavior and violence adding to the diverse studies that have not clarified the relation between them it may also be of great interest to the educational community because it contributes relevant data for the design of interventions promoting protector factors and reducing risk factors for example in the peer group it is also of interest to parents and in order to elaborate programs targeting the parents because as indicated family factors are highly involved in the origin of adolescents delinquent behaviors conflict of interest statement the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest the reviewer dá and the handling editor declared their shared affiliation and the handling editor states that the process nevertheless met the standards of a fair and objective review

the present study analyzes the relation between delinquent behaviors interpersonal values and academic performance it also analyzes the possible protective function of interpersonal values against delinquent behaviors the interpersonal values questionnaire ivq was used to assess interpersonal values and the antisocialdelinquent behaviors questionnaire ad was employed to assess antisocial behaviors the sample was made up of 885 students of compulsory secondary education aged from 14 to 17 years the results show that individuals who fail a subject as well as those who repeat a course present higher means in delinquent behaviors repeaters present higher means in the values of recognition and leadership and nonrepeaters in the value stimulation whereas students who do not fail obtain higher scores in the value benevolence students with high levels of recognition independence and leadership as well as students with low levels of conformity and benevolence display significantly higher levels of delinquent behaviors lastly the probability of presenting a high level of delinquent behaviors is greater in individuals with high independence high leadership high recognition low benevolence and low conformity

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the standard approach in nationally representative surveys is to ask mothers to think back to the time they became pregnant with their child and report whether the pregnancy was wanted then or wanted later or not at all 2 scholars have raised concern about various aspects of this approach ranging from its specificity to individual pregnancies to its discrete categorization of complex emotions but the most salient concern relates to the issue of timing most surveys rely on mothers retrospective recall of their intentions after the pregnancy has already ended in the birth of a child allowing women to possibly engage in ex post rationalization 3 longitudinal studies show that womens reports of intentions of the same pregnancy change when asked at different stages of reproduction whereas women who revise their reports typically shift from unintended to intended over time select studies have documented revision in the opposite direction as depicted in figure 1 key maternal experiences that occur between the time of conception and the time at which women retrospectively report their pregnancy intentionsincluding childrens health experiencescould instigate this revision process despite this the large literature on unintended pregnancy and child health especially in lowincome contextsrelies mostly on crosssectional data that measure child health outcomes and mothers retrospective reports of pregnancy intentions at a single point in time leaving open the possibility that childrens health outcomes influence mothers reports crosssectional studies of unintended pregnancy and child mortality may be particularly susceptible to endogeneity the death of a young child is a traumatizing and stigmatizing experience that may lower a mothers likelihood of reporting that the deceased child resulted from an unintended pregnancy either because she internally recalls the pregnancy in a positive light or she revises her report in the facetoface interview to avoid blame in this paper we examine the relationship between child mortality and mothers retrospective reports of pregnancy intentions in the context of subsaharan africa a world region where rates are high for both unintended pregnancy and child mortality we use crosssectional demographic and health survey data from 31 subsaharan african countries these data feature detailed 1978 pérezescamilla et al 1999 taylor andcabral 2002 and receive less preventative healthcare including childhood immunizations compared to their peers born from intended pregnancies extending evidence of an association between unintended pregnancy and maternal behaviors longitudinal studies further confirm that children from unintended pregnancies face longterm health risks ranging from low birth weight to overall poor health and development in later childhood with some direct evidence that unhealthy maternal behaviors explain these adverse outcomes children from unintended pregnancies even experience a higher risk of death in settings as diverse as the united states bangladesh and india though selection could account for some of this association these studies offer compelling evidence that children from unintended pregnancies experience longlasting severe consequences crosssectional studies generally produce findings that align with longitudinal evidence that children from unintended pregnancies experience worse subsequent health however this is not the case for crosssectional studies of child mortality which have shown associations in the opposite direction for instance montgomery and colleagues study using retrospective measures of mothers pregnancy intentions and child mortality found that children from pregnancies labeled unintended were more likely to be alive at the time of the survey although the correlations did not meet the threshold of significance in multivariate models a recent study from india similarly reports results from their full representative samples suggesting that unintended pregnancy is associated with child survivalnot mortality other evidence however suggests a null association 5 combining longitudinal evidence that children born from unintended pregnancies have higher subsequent mortality with crosssectional evidence of either an opposite or null relationship suggests that the crosssectional nature of these data could be biasing the findings specifically we hypothesize that a child having died before the survey may bias a mothers retrospective report of her pregnancy intentions though past research argues that mothers are prone to recall lower quality unhealthy children resulted from unintended pregnancies in the following section we discuss why mothers may be reluctant to declare deceased children resulted from unintended pregnancies child death and mothers retrospective reports of unintended pregnancy there are two explanations for why a mother may be less likely to report a deceased child resulted from an unintended pregnancy compared to a living child first a childs death may change the way a mother internally recalls the pregnancy including whether she desired it at the time of conception the death of a young child is a traumatizing experience with longterm psychological consequences some researchers argue that mothers in highmortality contexts maintain emotional distance and ambivalence toward infants precisely because of this high risk of premature death but evidence from africa confirms child death is an emotionally taxing experience for mothers for instance anthropological work in mali west africa highlights womens profound grief when talking about a deceased child even decades after the death the feelings of loss and sadness surrounding a childs death may lead women to reflect on the childand the pregnancyin a more positive light independent from a mothers actual or enhanced memory of the deceased child and the related pregnancy in facetoface interviews mothers may be more comfortable reporting the pregnancy was intended the social organization of childrearing puts extensive responsibility on mothers for their childrens health and social narratives of good mothering blame mothers when children do not thrive this is certainly the case when young children die evidence from subsaharan africa shows that community members commonly agree that mothers bear some responsibility for their childrens death as a result a mother whose child is no longer alive may be apprehensive to tell an interviewer the child resulted from a pregnancy that was poorly timed or unwanted childs age at death and mothers retrospective reports of unintended pregnancy the tendency for a mother to internally recall the pregnancy of a deceased child more favorably or shift her external report of the pregnancy in an interview setting may be heightened for children who died at older ages versus those who died early in infancy the tendency for women to remember pregnancies in a more favorable light has been shown to increase with the childs age which may reflect their growing attachment to the child over time if mothers form a stronger bond with children as they age though losing a child at any stage of reproduction including preconception has negative psychological consequences losing an older child may produce the greatest sense of loss and thus more powerfully color womens recall of the pregnancy the death of an older child versus a very young infant may also more strongly discourage women from reporting in an interview setting that the child resulted from an unintended pregnancy whereas reproductive complications and genetic factors lead to most infant deaths preventable causes underlie most deaths among children older than 1 year thus mothers whose children die after infancy may feel greater culpability for the death because it is more likely to have stemmed from a preventable illness such as a respiratory virus or malaria as a result these mothers may feel the greatest guilt and be the least apt to outwardly label a deceased child as the result of an unintended pregnancy current study in this study we explore whether a childs vital status is associated with a mothers retrospective report of the intentionality of the pregnancy from which the child resulted the high rates of unintended pregnancy and child mortality in contemporary subsaharan africa motivate our focus on the region recent estimates suggest that 8 out of every 100 pregnancies in subsaharan africa are unintended 6 the rate of unintended pregnancy has declined slightly in recent years yet more than onethird of all pregnancies in the region are reportedly unintended moreover one in every ten children in subsaharan africa dies before their 5th birthday if we find that mothers are less likely to label deceased children as unintended compared to living children this may not mean that child deaths cause mothers to positively revise their pregnancy intentionsas we hypothesizebut instead could indicate that children resulting from unintended pregnancies actually have a lower risk of dying than children from intended pregnancies if the latter explanation drives our findings because both illness and stunting are positively correlated with child mortality children from unintended pregnancies should also have better health to test whether this is the case we analyze parallel associations between more benign indicators of poor child health and mothers retrospective reports of pregnancy intentions among children who are still alive if results from these analyses confirm that mothers reports of unintended pregnancy is linked with poor child health but lower risk of dying this will suggest that a childs death uniquely influences mothers retrospective reports of pregnancy intentions tanzania uganda zambia and zimbabwe the dhs program is a nationally representative survey fielded to a crosssectional sample of participants every five years the dhs uses a stratified random sampling approach with clusters providing the primary sampling unit within each selected cluster the dhs randomly samples families household heads complete a full roster of household members from which the dhs identifies eligible women between the ages of 15 and 49 the dhs asks women to retrospectively report their pregnancy intentions for each pregnancy that resulted in a live birth in the previous five years because some women in the sample had more than one birth in the past five years to ensure cases are independent we restrict the sample to womens most recent birth less than 1 percent of births are missing data we exclude those cases and arrive at a final sample of 189571 children for analyses of the association between child health and mothers reports of pregnancy intentions although only 1 percent of children are missing data on child illness the anthropometric data we use to classify children as stunted are not available in many instances furthermore because of the challenges associated with measuring small children interviewers frequently flagged the anthropometric data as possibly inaccurate although results are consistent when using the full sample of living children for parsimony in the analyses of recent child illness and stunting we rely on the sample of 106193 living children with valid anthropometric data 7 measures unintended pregnancy for each child born in the five years preceding the survey dhs interviewers ask mothers at the time you became pregnant did you want to become pregnant then did you want to wait until later or did you not want to have any children at all this retrospective measure closely parallels survey items in the national longitudinal survey of youth the national survey of families and households and the national survey of family growth each of which are highly regarded data sources frequently used to study pregnancy intentions in the united states we take the standard approach of categorizing a pregnancy as unintended if the mother reported it was wanted later or not at all versus intended if the mother reported the pregnancy was wanted at that time in supplemental analyses we used a threecategorical measurement approach to confirm that key associations between childrens vital status and mothers reports of pregnancy intentions are consistent when analyzing mistimed and unwanted pregnancies separately 7 to test the robustness of our results to sample restrictions we conducted supplementary analyses on two additional samples first rather than focusing on the most recently born child in the past five years we randomly selected one child from each mother second because birth order is very closely correlated with pregnancy intentions child survival and child health in a second set of parityrestricted estimates we reestimated the models focusing only on firstborn children each additional set of models produced estimates that are similar in size and statistical significance as those reported in the tables child vital status women complete full birth history calendars which include information on whether each child is still living at the time of the survey we first use a binary indicator of whether the child is alive versus deceased in a second model set we further categorize deceased children according to their having died in infancy versus later childhood child health recent illness and stunting we leverage data on recent illness and nutritional status of living children to gain a better sense of whether the association between a mothers retrospective report of the pregnancy and a childs death is unique from other measures of poor child health in terms of illness mothers report whether all living children had a cough accompanied by short rapid breathing a fever or diarrhea in the two weeks preceding the survey these items are widely used in child health research in lowincome countries we differentiate between children who experienced no symptoms of illness and those who experienced one or more in terms of nutritional status we use available anthropometric data on living childrens height and age to capture stunting using recommendations by the world health organization the dhs records the number of standard deviations below the international reference population each childs height is for their age group severe stunting is most commonly defined as more than two or three standard deviations below the average however because minor growth restriction is the first indication of a childs failure to thrive especially among young children and is a significant cause of child mortality we use a broader categorization we code a child as displaying evidence of minor to severe stunting if they fall more than one standard deviation below the international reference population we code children who are less than one standard deviation below the reference population and those who are above it as controls we control for a number of child and maternal characteristics that may be associated with both childrens healthsurvival and womens reports of pregnancy intentions in terms of child factors we account for gender and birth order we also account for the number of years that have lapsed between the time of the childs birth and the date of the survey which is associated with childrens wellbeing as well as womens likelihood to recall a pregnancy as intended because the risk of unintended pregnancy differs according to mothers marital status we control for mothers marital status at the time of the survey a mothers marital status at the time of the survey might differ from her status at the time she became pregnant however this is impossible for us to know because the dhs does not include data on the dates of each union formationdissolution to address the fact that we have imperfect information on womens marital status we also include an indicator for whether a mother has been married more than once furthermore we account for additional maternal characteristics known to influence child health and pregnancy intentions including age at the time of the childs birth highest year of school attained and religion the likelihood of unintended pregnancy may vary by socioeconomic status so we control for the dhs wealth index the dhs aggregates information on households assets and characteristics into a principal component factor analysis the dhs then uses the factor scores to categorize households into five quintiles which we use here poorest reference poor middle rich or richest in addition to the wealth index we account for whether a household is headed by a female versus a male and whether it is in a rural versus urban community analytic strategy our analyses proceed in three steps first we provide descriptive statistics to characterize the children in our study second we estimate logistic regression models to assess whether mothers are less likely to retrospectively label deceased children as the result of unintended pregnancies because a countrys political cultural and economic climate is associated with both child mortality and unintended pregnancy we take a countrylevel fixedeffects approach by including a set of dummy variables representing each of the 31 countries in our sample this modeling strategy enables us to conservatively account for constant unobserved countrylevel factors that may confound the associations of interest and to produce estimates that compare the experiences of women within countries in these analyses we also disaggregate deceased children according to whether they died during infancy versus later childhood to confirm whether the findings vary by the childs age at death third we estimate a parallel set of countrylevel fixedeffects logistic regression models to assess the likelihood that less healthy children are more likely to be retrospectively labeled as from an unintended pregnancy focusing specifically on two indicators of poor child health recent illness and stunting results descriptive findings table 1 gives an overview of the analytic samples the first column characterizes the full sample of children including those who were no longer alive at the time of the survey nearly onethird of the childrens mothers retrospectively reported that the child was from an unintended pregnancy which is similar to the percentage among the subsample of living children shown in the second column the descriptive statistics further show that among the full sample 6 percent of these children were no longer alive at the time of the survey among the subsample of children who were still alive more than onethird had experienced a cough diarrhea or fever in the past two weeks more than onehalf of children showed evidence of stunting that is they were more than one standard deviation below appropriate height for their age the percentage of children stunted in our sample is slightly higher than commonly published international rates because of our inclusion of children who are mildly stunted the results further show that in each sample approximately onehalf of children are female and are on average the third born for the average child in our sample the survey occurred slightly less than two years after their birth at the time of the survey most of the childrens mothers were married although a nonnegligible percentage of mothers had never been married or were currently divorcedseparated or widowed most childrens mothers gave birth between ages 20 and 34 years had just over three years of education and lived in a rural area figure 3 shows the bivariate association between child health and survival and mothers retrospective reports of whether the child resulted from an unintended pregnancy the results confirm that deceased children are more commonly reported to be from intended pregnancies compared to their living peers8 however in line with existing theory and evidence we find the opposite is true for more benign measures of child health compared to their healthier peers mothers more often report that recently ill or stunted children were from unintended pregnancies child death and mothers retrospective report of the pregnancy in tables 2 and3 we present results from fixedeffects logistic regression models to demonstrate the extent to which the above patterns are robust to inclusion of covariates each table reports odds ratios a value below 1 implies a negative association meaning the mother is less likely to have reported an unintended pregnancy an odds ratio above 1 implies a positive association meaning a higher likelihood of reporting the child resulted from an unintended pregnancy beginning with table 2 model 1 shows that mothers are significantly less likely to report deceased children were from an unintended pregnancy net of childrens gender and birth order deceased children had 26 percent lower odds of being reported as resulting from an unintended pregnancy compared to children who were still alive at the time of the survey including the full set of controls in model 2 slightly attenuates the size of the association however deceased children continue to have 23 percent lower odds of being reported as the result of an unintended pregnancy compared to children who were alive at the time of the survey the results also confirm higher odds of resulting from an unintended pregnancy among children who were born to nevermarried mothers born to teenagers residing in femaleheaded households and living in rural areas the results in table 3 confirm that the magnitude of the association between childrens vital status and mothers reported pregnancy intentions varies according to the age at which the child died compared to living children a child who died in infancy has 17 percent lower odds of being reported as resulting from an unintended pregnancy whereas a child who died at an older age has 37 percent lower odds of being reported as the result of an unintended pregnancy additional analyses confirms that compared to children who died in infancy children who died at an older age have 17 percent lower odds of being reported as the result of an unintended pregnancy thus although all deceased children are less likely to be labeled as the result of an unintended pregnancy this is especially true of children who died at older ages poor child health and mothers retrospective report of the pregnancy to confirm whether this finding is particular to childrens vital status table 4 provides model estimates of the association between more benign indicators of child health and mothers retrospective reports of pregnancy intentions beginning with child illness the results in model 1 confirm thatin line with the large literature linking unintended pregnancy to worse child healthcompared to children with no recent illness mothers are more likely to report that children who have experienced a recent illness are from unintended pregnancies in fact recently ill children have 53 percent higher odds of their mother reporting they resulted from an unintended pregnancy the results in model 2 confirm that the same is true for stunted children who have 4 percent higher odds of being reported as the result of an unintended pregnancy compared to children who show no signs of growth faltering the fact that we find the anticipated associations between unintended pregnancy and two common indicators of poor child healthbut the opposite when examining child deathsuggests factors specific to a childs death lead women to shift their internal recall andor external report of whether the associated pregnancy was intended because unintended pregnancies include mistimed and unwanted pregnancies in supplemental analyses we use a multinomial modeling approach to analyze the distinct associations between child health and mortality and each type of unintended pregnancy the results confirm that compared to their healthier peers recently ill and stunted children are more likely to be reported as the result of a mistimed or unwanted pregnancy versus an intended pregnancy we also include model estimates for deceased children which confirm that deceased children are significantly less likely to be reported as resulting from a mistimed or unwanted pregnancy compared to their living peers the remarkable similarity in the size of the coefficients confirms that mothers of deceased children are just as likely to retrospectively report that the pregnancy was mistimed as they are unwanted discussion much of the debate about how best to measure pregnancy intentions centers on the appropriateness of asking women to recall intentions regarding pregnancies that have already concluded with the birth of a child fertility scholars have long expressed concern that womens retrospective reports of pregnancy intentions may be different from their actual feelings at the time of conception child health outcomes may prompt this revision however despite possible endogeneity the vast majority of child health research on the consequences of resulting from an unintended pregnancy relies on crosssectional data leaving open the possibility of reverse causation this is especially problematic for child mortality research that relies on retrospective reports past research argues that mothers are prone to retrospectively recall lower quality that is unhealthychildren resulted from unintended pregnancies though we document such an association here we also find that mothers are less likely to report deceased children especially those who died in later childhoodresulted from unintended pregnancies why are mothers less likely to report deceased children resulted from unintended pregnancies compared to their surviving peers we argue that this is most likely because women either internally recall these pregnancies more positively andor externally revise their reports of what were in many cases unintended pregnancies the lack of data on womens reports of their pregnancy intentions at the time of conception however disallows us from confirming that this is true that is directly testing whether a childs death provokes a mother to revise her report of the pregnancy from unintended to intended requires longitudinal data with mothers reports both at the time of the pregnancy and after the childs birth though we are not aware of such data from any of the subsaharan african countries we study here such data are available on a group of women from upper egypt in 199697 the egypt indepth study of reasons for nonuse of family planning sampled a group of reproductive age women from upper egypt who had participated in the 1995 egyptian demographic and health survey the 1995 edhs asked 1548 women who were pregnant at the time of the survey whether their current pregnancy was wanted at the time of conception later or not all a total of 381 of these women participated in the eis at which time they reported whether the resulting child still alive and again were asked if the pregnancy from which the child resulted was wanted at the time of conception later or not at all a total of 17 percent of the 381 mothers initially reported their pregnancy as unintended when pregnant but later reported the same pregnancy was intended after giving birth moreover a total of six percent of the 381 pregnancieschildren on which women report died between mothers reports 41 percent of deaths occurred in the first month of life and 59 percent after the first month but before the first birthday supplemental logistic regression models 9 confirm that a child having died within the first year of life is associated with a significant increase in the odds that a mother initially reported the pregnancy was unintended but later revised her report to intended these results powerfully bolster our argument that our main findings likely reflect the fact that a childs death provokes mothers to revise their report of pregnancy intentions so that the deceased childregardless of whether they were intendedare labeled as such we offer two possible explanations for this revision process womens memories of their pregnancies shift after the traumatic experience of a childs death andor women provide a positive report in the interview setting to avoid blame our results in appendix c could be taken as some albeit indirect indication that the former process is at play these results demonstrate that deceased children are equally less likely to be labeled as unwanted or mistimed versus intended in an interview setting reporting that a deceased child was from an unwanted pregnancy should be more stigmatizing than reporting the child was from a pregnancy that occurred too soon so it is surprising that mothers are equally likely to report deceased children as mistimed or unwanted this might indicate that the association is not necessarily a reflection of womens desire to avoid social stigma in the interview setting rather women are more likely to simply recall the pregnancy in a more positive light on the other hand a study by frenzen and hogan in rural thailand could be taken as indirect support that the latter explanationwomen externally revise their reports in the interview settingcould be at play their study is unique for two reasons it relied on womens reports of their own and their husbands views of whether the pregnancy was unintended and it is one of the only crosssectional studies that shows children from unintended pregnancy have higher mortality that is the study finds that child death was more common among pregnancies retrospectively reported as unintended by the childs mother or father this suggests that in interviews women may more openly declare a deceased child as being from an unintended pregnancy when the lack of intention can also be attributed to her husband the data needed to separate these mechanisms make identifying whichif eitheris operating a formidable challenge another possible way to gain some traction on the salience of each explanation with existing data is to investigate whether the findings vary across highversus lowmortality contexts to approximate for differing levels of stigma attached to child death because we assume that womens emotional response to a childs death will be comparable across settings regardless of how pervasive child mortality is if deceased children are especially unlikely to be reported as unintended in communities where child death is rare but more commonly reported as unintended in communities where child death is more normative this may reflect the fact that stigma and shame are leading women to externally report the deceased child as having been intended thus future work that leverages heterogeneity in contexts may provide insight into the social conditions that make women especially apprehensive to report that a deceased child was from an unintended pregnancy and thus may illuminate the mechanisms at play if our findings are in fact driven by womens apprehension to report deceased children resulted from unintended pregnancies shifting the mode of data collection to computerassisted personal interviewing could overcome this problem but even more minor changes to existing survey endeavors could help using the dhs as an example immediately preceding questions on pregnancy intentions interviewer protocol is to say now i would like to ask you some questions about the health of all of your children… referencing the child by name one of the first topics discussed in the section on child health is whether the pregnancy was intended most mothers are generally apprehensive to label pregnancies as unintended in facetoface interviews but mothers may be especially unlikely to do so after being prompted to think about the deceased childs health separating discussion of child health outcomes from discussion of pregnancy intentions may reduce the risk that women feel uncomfortable reporting the associated pregnancy was unintended of course future studies that track womens pregnancy intentions over time and use complementary forms of data collection are needed to confirm whether and how the interview setting may prompt women to revise their retrospective reports of intentions of course the interview setting may also discourage women from reporting deceased children all together that is there are probably a nonnegligible number of instances in which women do not report the pregnancies or births of children who have died meaning that the true level of child death in our data is likely underestimated however most research suggests that underreporting of child deaths is most common for children born more than 10 years prior to a survey in this study we focus only on children born within the past five years and specifically womens most recently born child if mothers whose deceased children were unintended are less likely to report the birth at all compared to mothers whose deceased children were intended this could also result in underreporting of unintended pregnancies if such underreporting is occurring in our data and if it is affecting levels of unintended pregnancies it is unlikely to influence the associations documented here because women will most likely omit all reference to the deceased child that is the underreporting of child death is correlated with womens report of the pregnancy longitudinal studies that track women and children over time will also help to address the possible underreporting of child death the findings suggest that studies leveraging crosssectional data on unintended pregnancies and child mortality are especially vulnerable to underestimating the true consequence of unintended pregnancy for child survival research on child health may also be vulnerable to issues of endogeneity that is if our crosssectional findings reflect that mothers are more likely to label unhealthy children as resulting from unintended pregnancies this will overestimate the true consequences of unintended pregnancy on child health a study comparing the associations between retrospective versus prospective measures of intentions and child health in the united states suggests that timing of report does not overestimate the size of the relationship between particular child health outcomes but this issue should be more carefully explored in longitudinal studies of contexts where child health problems are frequent and often severe such as contemporary subsaharan africa the results also point to the need for population estimates of pregnancy intentions to use prospective measurestaken before a child is bornor innovative nonpregnancyspecific measures to ensure that child outcomes are not systematically influencing published estimates of the level of unintended pregnancy beyond its implications for studying pregnancy intentions the studys results also inform the broader literature on child mortality highlighting the need for data on not only its causes but also its consequences child mortality rates are declining across subsaharan africa but child death remains a relatively common maternal experience and this is unlikely to change in the coming decades only 6 percent of children in the sample had died but focusing on women confirms that child death is a far more pervasive phenomenon approximately 30 percent of mothers in our dataset had experienced a child death among women in subsaharan africa who are nearing the end of their reproductive careers nearly 60 percent have lost a child the vast majority of research on child death approaches it from a social problems perspective focusing on identifying its causes rather than its consequences but a childs death has great significance for a mother and even her friends our study highlights the value of research that recasts the focus on child death as both a social problem and an intimate experience that shapes womens experiences and one that also complicates efforts to understand womens reproductive intentions and desires data and sample we use the most recent dhs data available from the 31 subsaharan african countries in which a survey was administered since 2000 benin burkina faso burundi cameroon chad congo democratic republic of the congo ethiopia gabon ghana guinea ivory coast kenya lesotho liberia madagascar malawi mali mozambique namibia niger nigeria rwanda sao tome principe sierra leone senegal swaziland appendices

social scientists have long debated how to best measure pregnancy intentions the standard measure relies on mothers retrospective reports of their intentions at the time of their conception because women have already given birth at the time of this report the resulting childrens health including their vital statusmay influence their mothers responses we hypothesize that women are less likely to report deceased children were from unintended pregnancies and this may explain why some longitudinal studies have shown that children from unintended pregnancies have lower survival but crosssectional studies produce counter findings using demographic and health survey data from 31 subsaharan african countries we confirm that mothers are less likely to report deceased children resulted from unintended pregnancies compared to surviving children although the opposite is true for unhealthy children who mothers more commonly report were from unintended pregnancies compared to healthier children the results suggest that mothers 1 revise their recall of intentions after the traumatic experience of child death andor 2 alter their reports in the facetoface interview the study challenges the reliability of retrospective reports of pregnancy intentions in high mortality settings and thus our current knowledge of the levels and consequences of unintended pregnancies in these contexts

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introduction areabased measures of socioeconomic position are used to investigate the effect the socioeconomic characteristics of a place has on health over and above individual attributes they may also be used as a proxy for missing individuallevel data for example in the context of adjusting for confounding for socioeconomic factors it is widely recognised that poorer individual socioeconomic circumstances are generally associated with less favourable health outcomes1 areabased sep is also associated with a range of health outcomes24 including allcause and causespecific mortality5 and these associations often continue to be observed after controlling for individuallevel socioeconomic factors 6 in the uk the areabased deprivation indices of jarman townsend and carstairs and the breadline britain index were pioneering efforts to capture the socioeconomic profiles of areas which cover several domains of the socioeconomic standing of a neighbourhood or area7 the townsend index for example is based on unemployment households not owneroccupied households without cars and overcrowded households8 more complex measures of multiple deprivation which go beyond census data were developed in more recent years the english indices of deprivation 9 are based on income employment health and disability education and skills access to services and housing living environment and crime lack of access to public services including access to healthcare is a new domain of deprivation which is particularly relevant in rural areas 10 the definition of neighbourhoods and areas when developing such indices is not straightforward most analyses have hitherto been based on fixed boundaries using administrative or census units and were driven by the availability of data arbitrary boundaries lead to what geographers describe as the modifiable areal unit problem where different scales and aggregations of data yield different results 11 the problem is related to ecological bias and the ecological fallacy in epidemiology12 automated zone design methodology has been used to maximise social homogeneity within areas13 however the approach still depends on fixed areas areas centred on individuals residences with sliding rather than fixed boundaries define neighbourhoods that aim to capture the environmental and social conditions to which an individual is exposed to road network data can be used to define individual exposure areas with their shape distorted in the direction of the nearest major roads with shops services and public transportation 14 in switzerland sociocultural indices have been developed based on administrative units and 1990 and 2000 census data15 an areabased index of sep suitable to characterise individuals in epidemiological research is however lacking we used georeferenced census 2000 and road network connectivity data to develop the swiss neighbourhood index of socioeconomic position a householdcentred neighbourhood index with sliding boundaries we examined the construct validity of the index by exploring its association with income and financial deprivation in the swiss household panel a longitudinal study following a random sample of swiss households 16 finally we investigated the associations with allcause and causespecific mortality in the swiss national cohort 17 methods the development validation and application of the swisssep index consisted of the following five steps the definition of neighbourhoods with moving boundaries around each of the 127 million buildings recorded in the 2000 census the characterisation of the socioeconomic standing of these neighbourhoods based on median rent education and occupation of household heads and household crowding the construction of the index by combining the loadings of the first component from principle component analysis the validation of the index using independent data on the financial situation of households and the analysis of associations between the swisssep index and allcause and causespecific mortality in the adult population resident in switzerland definition of neighbourhoods we used census 2000 data of all residential households in switzerland each household was spatially referenced using the geographic coordinates of 127 million residential buildings provided by the swiss federal statistical office we created sliding neighbourhood boundaries for each of the buildings on the basis of road network connectivity using network analyst extension of arcgis and the road network model derived from the 2009 tele atlas multinet database we included major roads secondary and local roads motorways and slip roads were excluded because they tend to divide communities rather than provide connections within them we created 127 million overlapping areas centred on each of the residential buildings in turn consisting of about 50 of the nearest households the target number of households within neighbourhoods was in line with the statistical output areas used for the 2000 uk census18 if the 50 th household was located in a building with more than one household the other households in the building were also included figure 1 shows a hypothetical example of an area created for one household socioeconomic standing of neighbourhoods we conceptualised the swisssep as a composite measure covering four domains income education occupation and housing conditions each domain was represented by one variable each variable represented data aggregated on the level of neighbourhood no data on household income are collected in the census and we therefore used the median rent in swiss francs per square metre of the 50 nearest rented flats we restricted the analysis to flats with three to five bedrooms apartments with fewer or more bedrooms were much more heterogeneous for example they included flats with one small bedroom or loft apartments for education we used the proportion of households headed by a person with primary education or less similarly occupation was represented by the proportion of households headed by a person in manual or unskilled occupations manual and unskilled workers were defined according to the eight lowest categories and farmers of the 33 grade socioprofessional categorisation of occupations developed by the swiss federal statistical office 19 the head of the household was the person economically responsible for the household as reported in the census finally we used crowding the mean number of persons per room combining bed and living rooms as the indicator of housing conditions construction of index pca on arealevel aggregated data was used to construct the index the first principal component consisted of the linear weighted function of the four variables covering income education occupation and housing we combined the loadings of the first principal component to form a score of the sep of a neighbourhood such that higher values indicated areas of higher sep pca was weighted by the number of households within the area to account for differences in the size of areas finally we averaged the values of the swisssep index for 2879 local authorities and 289 residential districts of 17 towns and cities reflecting the administrative structure of switzerland at the time of the census 200020 and compared analyses based on neighbourhoods with analyses based on the larger areas validation using household panel data we explored the association of the index with data on the financial situation of households recorded in the shp16 among 5074 households participating in the first wave of shp in 1999 we were able to geocode 4460 addresses using tele atlas data the address of the remaining households was either missing or incomplete we assigned the value of the index of the closest building for each of the geocoded shp households we analysed selfreported information on household income and expenses contributions to taxfree private pension schemes and reception of financial help across deciles of swisssep in particular we calculated the yearly mean equivalised household income which adjusts for family size using the method of the organisation for economic cooperation and development mortality across deciles of index we examined the association of the index with mortality in the 431 million individuals older than 30 years included in the snc the snc is a national longitudinal study of mortality in switzerland based on deterministic and probabilistic linkage of census data with mortality records described in detail elsewhere the snc was approved by the cantonal ethics committees of bern and zurich17 we explored the associations of swisssep deciles with allcause and causespecific mortality during the years 2001e2008 we examined lung cancer breast cancer prostate cancer respiratory diseases cardiovascular diseases myocardial infarction stroke traffic accidents and suicide we used cox proportional hazard regression measuring time from the date of the census 2000 to the earliest of death emigration or 31 december 2008 all models were adjusted for age and sex results are represented as hrs with 95 cis p values were obtained from loglikelihood ratio test analyses were performed using stata software results the development of swisssep was based on data on 127 million neighbourhoods with 295 million georeferenced households and 667 million individuals recorded in the census 2000 the mean size of overlapping neighbourhoods was 527 households and 125 individuals with a median value of mean road distance between the reference building and the other buildings constituting the neighbourhood of 1305 m switzerland has relatively compact spatial distribution of residential buildings therefore in 90 of cases the information about aggregate characteristics of neighbourhoods came from buildings within 700 m along the road network the first principal component retained to construct the index explained 547 of the total variance education occupation and housing domains had positive loadings of 0578 0570 and 0362 respectively and income had a negative loading of 0459 we standardised the index to a range of 0 to 100 with a median of 6332 seven of the 10 lowest swisssep neighbourhoods were found in a municipality of canton aargau and six of the 10 highest in a municipality on the gold coast of the lake of zurich younger people and immigrants were more likely to live in decile 1 neighbourhoods whereas older people and the swiss were more likely to be residents of decile 10 areas the proportion of frenchand italianspeaking neighbourhoods declined with increasing sep and the proportion of germanspeaking neighbourhoods increased 767 of neighbourhoods in decile 10 were german speaking compared with 453 in decile 1 compared with protestants catholics were more likely to live in decile 1 neighbourhoods whereas individuals with no afflliation were more common in decile 10 areas figure 2 shows a map of the 127 million neighbourhoods neighbourhoods of higher sep are concentrated in the urban centres most notably in zurich geneva basel lausanne bern and surroundings and along some of the lakes for example the arc of lake geneva and both sides of lake zurich neighbourhoods of lower sep dominate the regions immediately north of the alps that are free of lakes the area north of the lakes of neuchâtel and bienne in the west of the country and much of the valleys of the alps the analysis of the 4460 households from the shp showed that with increasing level of neighbourhood sep equivalised yearly income of households increased mean household income increased from about sfr42 000 in decile 1 to sfr72 000 in decile 10 trends in the same direction were observed for contributions to voluntary taxfree pension schemes whereas financial help was received by almost twice as many households in decile 1 compared with decile 10 the proportion of households reporting that all the income was spent on current expenses decreased from 485 to 357 between the first and 10th decile the swisssep index was associated with allcause and causespecific mortality the ageand sexadjusted hr comparing neighbourhoods within decile of lowest sep with highest was 138 for allcause mortality with a clear gradient across deciles stronger associations in the same direction were seen for lung cancer respiratory diseases and traffic accidents there was little association with breast cancer mortality and an association in the opposite direction for suicide hrs were attenuated when further adjusted for nationality marital status level of urbanisation individuallevel education and professional status but important associations remained finally repeating analyses using mean values of the index for the 2879 local authorities and 289 urban districts resulted in a weaker association with mortality from allcauses with the increase levelling off between first and sixth deciles discussion we developed an areabased index of sep for switzerland the swisssep based on data on income education occupation and housing obtained from the 2000 census the census collected data on education and occupation of the heads of households and on housing the data on housing allowed us to use crowding as an index of housing conditions and also provided a proxy measure for income that is the median rent per square metre of note only 34 of homes are owneroccupied switzerland has the lowest rate of home ownership in western europe 21 the analysis of independent data from the shp study showed that the index has criterion validity with a clear trend in equivalised mean household income across deciles of the index finally the index was associated with mortality from allcauses and more strongly with causes associated with socioeconomically patterned behaviours such as smoking or diet for example the index was strongly associated with lung cancer and cardiovascular mortality strengths of the study a novel aspect of the development of swisssep was the definition of neighbourhoods using moving boundaries based on road connectivity to our knowledge this is the first example of an areabased index of sep using such techniques egocentred neighbourhoods with sliding boundaries overcome some of the conceptual problems associated with fixed boundaries the widely used political or administrative boundaries were not designed for this purpose and are often too large and heterogeneous we used the road network to model relations between buildings thus taking into account spatial accessibility and natural and manmade barriers the move from arbitrary fixed boundaries to boundaries defined by relations should thus better capture interactions between and within areas and help to prevent aggregation bias 14 we a priori chose the domains of income education occupation and housing based on theoretical considerations22 income directly measures the material resources available in a household which can influence a wide range of material circumstances and access to services with direct implications for health the educational attainment of household heads captures the knowledgerelated assets of a household households with a higher level of education may be more receptive to health education messages and more able to communicate with and access appropriate health services the occupation of the head of the household is a reflection of its social standing occupation is strongly related to education and income and may also capture occupational exposures such as work stress control and autonomy and specific exposures at the workplace23 housing characteristics measure material aspects of socioeconomic circumstances including housing tenure amenities and conditions we used crowding the mean number of persons per room as the indicator of housing conditions overcrowded households are often households with fewer economic resources and there may also be direct effects on health for example through the spread of infectious diseases 22 we explored other housing characteristics for example the availability of central heating but these were less discriminatory results in context with other studies previous studies largely relied on administrative areas and there is little research on the appropriate size of moving spatial units similar population size and homogeneity in terms of the areas socioeconomic characteristics will reduce misclassification and are therefore desirable attributes when developing an areabased index of sep schuurman and colleagues24 argued that the smallest areas possible should be used however very small spatial units will be difficult to characterise reliably and the danger of identifying individuals will increase our decision to define areas of 50 households was informed by the census output areas developed in the uk but nevertheless arbitrary our approach was more powerful than aggregating the data at the level of local authorities and urban districts resulting in a steeper mortality gradient the relatively small size of neighbourhoods allows a view of differences in sep across space in fine resolution and improves geographic visualisation by giving little emphasis to thinly populated areas swisssep data can of course always be aggregated into larger areas including administrative areas and results can then be shown using traditional choropleth techniques with their usual drawbacks 25 suicide was somewhat more common in areas of higher sep previous studies have reported conflicting results including no relation of area suicide rates with sep and associations with lower or higher sep26 interestingly analyses of smaller geographical units were more likely to show an association with lower sep than studies based on larger areas 26 in switzerland assisted suicide has become increasingly important in recent years it is legal if the motive is not selfish and several righttodie associations offer such assistance27 preliminary results from an ongoing analysis of the snc indicate that assisted suicide is more common among higher educated urban populations and this may at least partly explain the findings of the present study we found a weak statistically nonsignificant inverse association between sep and mortality from breast cancer two large american cancer society cohorts showed that breast cancer mortality was about 20 lower in women with grammar school education only compared with college graduates28 of note the association became weaker in multivariate analyses including parity and age at first birth a study of 12 european populations found similar educational gradients with breast cancer mortality29 limitations of the study our approach to measuring sep and constructing and validating the swisssep index has several limitations income is sensitive and difficult to assess it was not available in the census and the response rate in the shp was 82 only it is possible that this may have biased our analysis of the panel data our proxy measure for income the average rent per square metre in the neighbourhood may have the advantage of being more closely correlated with disposable income than gross income as rent will reflect what households can actually spend 22 the meaning of educational level and occupation varies for different birth cohorts older cohorts will be overrepresented in those classified as having lower education and occupations of lower socioeconomic standing and analyses stratified by age may therefore be warranted similarly income may be a less reliable indicator of sep in young and older adults income typically follows a curvilinear trajectory with age22 lack of access to public services including access to healthcare was particularly relevant in rural england10 access to public services is probably also relevant in remote and mountainous areas of switzerland however no data on access were available results from studies using swisssep will be difficult to compare with studies from other countries that used different instruments to assess the sep of neighbourhoods finally we followed the example of others30 31 and used pca to create the composite index of sep from a set of variables several other approaches have been suggested including multilevel modelling32 cluster analysis33 multicriteria analysis34 and bayesian factor analysis 35 future theoretical and empirical research should clarify which method is best used in different situations implications the swisssep index will be useful to the research community in switzerland and allow a better characterisation of the sep of study participants enrolled in clinicaland populationbased studies both in studies where individuallevel information on sep was not collected and in studies specifically examining neighbourhood sep over and above individual sep it already has been useful to gain a more detailed picture of the geography of sep in switzerland we will make the swisssep data available to interested researchers further information can be found at summary box what is already known on this subject indices of areabased sep are useful to substitute missing individuallevel data in epidemiological studies or to study neighbourhood effects on health over and above individuallevel sep indices are often developed using fixed administrative boundaries to define areas which are large and heterogeneous areabased measures of sep suitable for epidemiological research are lacking in switzerland what this study adds the swisssep was developed based on census 2000 data and road network connectivity between areas including 50 households with sliding boundaries swisssep was strongly associated with independent data on household income and mortality from allcauses and causes associated with socioeconomically patterned behaviours such as smoking or diet the index will be useful for clinicaland populationbased research in switzerland where individuallevel socioeconomic data are often missing and to investigate the effects on health of the socioeconomic characteristics of a place

backgroundareabased measures of socioeconomic position sep suitable for epidemiological research are lacking in switzerland the authors developed the swiss neighbourhood index of sep swisssep methodsneighbourhoods of 50 households with overlapping boundaries were defined using census 2000 and road network data median rent per square metre proportion households headed by a person with primary education or less proportion headed by a person in manual or unskilled occupation and the mean number of persons per room were analysed in principle component analysis the authors compared the index with independent income data and examined associations with mortality from 2001 to 2008 results127 million overlapping neighbourhoods were defined education occupation and housing variables had loadings of 0578 0570 and 0362 respectively and median rent had a loading of 0459 mean yearly equivalised income of households increased from sfr42 000 to sfr72 000 between deciles of neighbourhoods with lowest and highest sep comparing deciles of neighbourhoods with lowest to highest sep the ageand sexadjusted hr was 138 95 ci 136 to141 for allcause mortality 183 95 ci 171 to 195 for lung cancer 148 95 ci 144 to 151 for cardiovascular diseases 242 95 ci 194 to 301 for traffic accidents 093 95 ci 085 to 102 for breast cancer and 086 95 ci 078 to 095 for suicide

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introduction worldwide there has been an estimated 10fold increase in the prevalence of childhood obesity over the last forty years 12 which has been partly attributed to the changes in the environment and shifts in socioeconomic inequalities 34 there is a wellrecognised association between socioeconomic status and obesity 56 evident in children as young as 5 years for example in england 13 of the most deprived children are obese compared to only 6 in the least deprived areas 5 it has been suggested that there have been recent changes in social patterning of childhood overweight due to widening social inequalities 47 hence it is not clear if these associations are an enduring feature of childhood obesity or a characteristic of the emerging obesity epidemic increases in obesity in young children and increasing evidence for the developmental origins of health and disease in the context of obesity suggests that factors very early in life may play an important role 8 potential early life risk factors for childhood overweightobesity that have been repeatedly identified in multiple modern cohorts include birthweight rapid weight gain in infancy adverse childhood experiences and a small protective effect of breastfeeding 9 10 11 12 13 all these factors have the capacity to be influenced by ses which highlights the need to understand how they fit together in potential pathways to obesity this study therefore compares data from two birth cohorts from the same geographical area but at different time points that were not subject to the same confounding influences a postworld war ii cohort with low prevalence of obesity compared to a modern cohort with a higher prevalence of obesity our aim was to investigate if the relationships between early life risk factors socioeconomic status and childhood overweightobesity have changed over time specifically we hypothesised that the environment and socioeconomic determinants in early life will impact on childhood bmi in both cohorts but that the relative importance of early life factors and ses as predictors of childhood bmi and pathways and interactions between them will vary research design and methods cohorts the two birth cohorts were both form northeast england the region with the highest prevalence of childhood obesity in england 5 the newcastle thousand families study is an ongoing birth cohort based in newcastle upon tyne who were recruited shortly after birth in mayjune 1947 1415 the cohort included nearly all eligible births the cohort were followed throughout childhood utilising data collected by health visitors and schools until 15 years of age exhaustive information was recorded including infant feeding various social conditions and height and weight throughout childhood further details on key findings and data collected can be found in the cohort profile 1415 the gateshead millennium study birth cohort is an ongoing study which recruited participants shortly after birth in gateshead on the southern bank of the river tyne opposite the city of newcastle upon tyne the cohort included 83 of eligible infants born in recruiting weeks between june 1999 and may 2000 16 the cohort has been followed up throughout infancy and childhood with detailed questionnaires on growth feeding behaviour illness and social factors as well as having anthropometric measures taken by trained researchers further details on key findings and data collected can be found in the cohort profile 16 measurement of early life factors and other predictor variables the early life factors and covariates that were directly comparable across the two cohorts and measured at similar ages in ntfs maternal age and birthweight were recorded at the time of delivery and taken from hospital records all other factors were recorded by health visitors in gms birthweight gestational age maternal age and postcode were recorded at recruitment child weight was measured in a clinic at the 13month health check other variables were collected via questionnaires including adversity ses and breastfeeding recoding of the variables was the same for both cohorts except for ses and adversity whilst ses indicators at birth were not identical the aim was to examine social gradients in bmi and therefore data were compared using 5 ordinal groups in ntfs this corresponded to fathers occupation at birth coded according to the registrargenerals social classes a longstanding method for individuallevel socioeconomic classification 18 for gms the socioeconomic indicator was townsend deprivation index from 1991 census which uses enumeration districts as the unit of analysis with the northern region of england as the population for comparison for the calculation of the quintiles although an arealevel measure townsend score is a measure of material deprivation and was the most comparable classification for ses at birth in gms comparative parental occupational data were available in childhood for both cohorts although collected at slightly different time points to increase group sizes childhood parental occupation data were recategorised into most advantaged middle and least advantaged 18 adversity encompassed 8 months prenatal to 4 months postnatal in gms and birth to 1 year in ntfs and included parental separation police involvement abuse debt death or illness in the family breastfeeding categories were harmonised for both cohorts to never 4 weeks 4 weeks6 months and 6 months rapid infancy weight gain is a known risk factor for childhood owob as there were large differences in birthweight between the cohorts weight gain conditional on birthweight was examined conditional weight gain or thrive index accounts for normal catchup growth from low birthweight as a linear measure of weight gain adjusted for regression to the mean 19 birthweight and weightforage zscores were calculated using the british 1990 growth reference 20 and were used to determine rapid weight gain and rapid thrive rwg was determined as zscore12m zscorebirth rapid thrive was determined as rt 19 where r is the cohort regression coefficient of birthweightz on weightz both rwg and rt were analysed as dichotomised variables a 067 standard deviation change in weightforage zscore equivalent to crossing a growth centile band on a standard child growth chart 9 outcome data body mass index height and weight measures were available at age 9 for both cohorts and were used to calculate bmi height and bmi were transformed in standard deviation zscores using the british 1990 growth reference 21 using the zanthro program in stata 22 weight categories of healthy weight and overweightobese were based on uk90 clinical cutoffs 2023 the uk 91st centile is close to the iotf overweight threshold 24 while the 2nd is equivalent to 2 sd who threshold for moderate malnutrition analytical design the analysis had 4 stages 1 we first examined differences between cohorts in exposures at baseline 2 next we examined socioeconomic gradients in anthropometric measures across cohorts 3 we then evaluated associations between early life exposures and bmi outcomes and whether there were any interactions between cohort and early life exposures and between early ses and early life exposures 4 we then further examined changes in childhood bmiz stratified by early life rapid growth due to the differences in health risks for underweight and obesity uw were excluded from all regression analyses statistical analysis the representativeness of the study participants compared to the original cohort within cohorts as well as baseline differences between the two cohorts were examined using ttests chisquared or wilcoxon ranksum tests as appropriate to examine socioeconomic gradients in outcomes variation in owob bmiz and heightz by ses was assessed using chisquare tests or oneway analysis of variance with bonferroni correction multivariable linear regression was used to estimate associations between bmiz and exposures stratified by cohort to examine the effects of ses on exposurebmiz associations bivariate models were sequentially adjusted for ses at birth and childhood ses odds ratios with corresponding 95 ci for owob and explanatory variables were estimated using logistic regression combining data from both cohorts sesexposure and cohortexposure interactions were tested within models using likelihood ratio tests final models were adjusted for covariates with the best model informed by goodness of fit statistics although bmi assesses weight independent of height it remains correlated with height in children 25 in gms there was a stronger correlation between height and bmiz which was not evident in ntfs using measures that remain correlated may introduce greater bias when comparing groups that differ markedly in height 26 therefore models were adjusted for height to evaluate the associations that reflect adiposity independent of height 2728 as study members measured at age 9 were different for some characteristics compared to the remaining study members in both cohorts models were refitted using sampling weights weighting on the variables that differed between cohorts as a sensitivity analysis however weighting minimally altered results therefore unweighted results are presented additional sensitivity analyses examined rapid growth as it is frequently defined 9 by substituting rwg in regression models to assess the relative importance of the early life predictors of bmiz the final multivariable regression models were reconstructed as path models path analysis is an extension of linear regression which models relationships between dependent variables and two or more independent variables additional paths were added to the baseline model informed by a priori hypothesises and modification indices good model fit was a χ 2 value 005 root mean square error of approximation 005 and p of close fit 005 and a comparative fit index and goodnessoffit index 095 all direct paths with p 005 were modelled and standardised β coefficients are presented to demonstrate the relative effects across the cohorts confidence intervals were estimated using bootstrapping rt emerged as an important factor and therefore utilising the longitudinal data available bmiz trajectories were plotted based on early life growth bmi zscores were derived as formerly described using data available at various points in childhood for gms and ntfs statistical analyses were conducted in stata 14 and path diagrams using spss amos 240 results at age 9 anthropometric measures and socioeconomic measures were available for 676711 members of ntfs and 302475 of gms while there were 313 ntfs and 269 gms with full data for the multivariable models ntfs children on average had a lower bmiz than gms children and were shorter there were only 7 owob in ntfs compared to 33 in gms uw were excluded from all regression analyses gms n6 cohort differences in early life exposures there were differences in early life exposures and ses between the time periods in ntfs mothers were slightly older gestational length was slightly shorter with fewer extreme gestation age groups rapid growth was more common and adversity was less common on average birthweights were smaller however there were no differences in birthweight categories in ntfs breastfeeding initiation was more likely and duration was longer 855 were breastfed and 39 for over 4 months less than 7 of the ntfs cohort were in the highest occupational group compared to 349 in gms in childhood relationship between socioeconomic status and anthropometry there were no overall trends in bmiz by ses in either cohort there were more owob in the least advantaged group in childhood in the gms but no socioeconomic differences in bmi categories in ntfs however there were early life socioeconomic differences in height in ntfs the most advantaged were taller than the least the socioeconomic differences in height were smaller in gms and did not attain statistical significance interrelationships between early life risk factors ses and childhood bmi cohortexposure interactions were examined using pooled data with ntfs as the reference group there were interactions between cohort and birthweight rt and height no other statistically significant interactions were observed there was an interaction for adversity however this did not remain after adjustment for childhood ses path analysis the relationships between exposures and the indirect pathways to bmi are presented in the path model similar direct associations were also observed in the stratified regression models and in both cohorts rt had the largest effect on bmiz the early life factors explained more variation in bmiz in gms than ntfs in gms adversity rt and birthweight all had similar positive direct effects on bmiz rt and birthweight were also positively associated with height in ntfs sex and rt were the only factors that predicted bmiz in adjusted regression analyses ses was not directly associated with bmiz in either cohort and there were no consistent sesexposure interactions however ses had indirect effects in the gms cohort ses was associated with birthweight and height and attenuated the effects of adversity on bmiz the path model shows the relationships between early life variables with bmiz at age 9 arrows show the direction of the direct effects between variables the direct effects are the straightforward relationships not going through any other variable the indirect effect is the product of each component path and the total effects are the sum of direct and indirect paths all exposures had significant total and indirect effects on bmiz standardised beta coefficients are presented which represent partial regression coefficients between connected variables controlling for all prior variables 29 all direct effects were modelled and are represented by solid lines total effects are presented in brackets ses socioeconomic status bwtz birthweight zscore rt rapid thrive gest gestational age although group sizes were too small to estimate a multivariable model for ntfs rt was associated with increased odds of owob in the bivariate model in the multivariable model for gms rt was associated with increased odds of owob at age 9 socioeconomic advantage was associated with decreased odds of owob in gms however there were no significant sesexposure interactions for either cohort after adjusting for height the model explained more variation in owob and birthweight was no longer a significant predictor in the sensitivity analysis rwg was also associated with bmiz and the coefficients for both cohorts were similar in the gms owob sensitivity model adjusting for height removed the significant positive associations for rwg investigating early life rapid growth and bmiz throughout childhood rt was the factor associated with higher bmiz in both cohorts and increased odds of owob and no other tested variables predicted rt the impact of rt on bmi zscores over time was examined further by definition those with rt show a sizeable increase in zscore from birth to 12 months within cohorts those who had rt had higher bmi zscores throughout childhood compared to those who did not however in ntfs at age 13 it was not significantly different in gms those who had rt also had a large initial increase in zscore but bmiz remained elevated and on average these children were 1sd above average bmiz throughout childhood figure 2 changes in mean zscore over time by cohort and rt error bars represent 95 confidence intervals average values were used for the interval ages for gms discussion summary of results these data provided an opportunity to consider whether risk factors for raised childhood bmi were the same in two different cohorts in the same geographical area one recorded before and the other during the obesity epidemic between the two periods height and prevalence of owob had greatly increased the social class differences in height that were evident in the historic cohort have diminished over time and instead socioeconomic differences in owob have emerged in the modern cohort there have been increases in birthweight and decreases in the duration of breastfeeding and of rapid infancy growth those who had rapid growth had higher bmi throughout childhood in both cohorts but there was increased likelihood of subsequent owob only in the modern cohort early life exposures that were unrelated to bmi in the historic cohort explained substantially more variation in childhood bmi in the modern cohort which may be related to the environmental changes that have occurred between the two time points consistency with previous findings this study is one of many to demonstrate that early rapid growth is associated with a higher child bmi and increased likelihood of childhood obesity 910 genetic variants for adult bmi are also associated with infancy growth suggesting that early infancy weight gain is on the pathway to adult obesity risk 29 therefore rapid growth in infancy may be a precursor to childhood obesity or could reflect the individuals predestined growth trajectory height mediated the effects of birthweight and rt on bmiz which may suggest that some of these associations were related to lean rather than fat mass 30 other studies have suggested that the relationship between rwg and subsequent adiposity is a marker of fast growth and later height 31 this may be a product of modern environments as the effects of rapid growth were previously unrelated to height but are now somewhat mediated through height early life risk factors that may have changed over time included birthweight and adversity which were only associated with bmiz in the modern cohort gms children had higher birthweights which is in line with previous findings that birthweight has increased over a generation 32 early life postnatal factors were the focus of these analyses however there are many maternal factors that can influence birthweight and offspring bmi 303334 this study does not support associations between breastfeeding with early childhood growth and bmi 35 36 although previous findings are not consistent and may be due to confounding by ses 37 38 39 previous analyses in the gms cohort have found a positive association between ses and breastfeeding duration 40 wright et al also noted more rapid growth in the gms cohort in those who stopped breastfeeding earliest although this is likely a result of reverse causation that babies genetically destined to be larger make greater demands on their mother for breastmilk and this greater demand increases likelihood of earlier cessation 41 we hypothesised that early life risk factors may interact with early ses but did not find strong evidence of this however we did identify socioeconomic differences in anthropometric outcome measures early life ses may reflect developmental programming effects whilst childhood ses may more likely be a marker of detrimental environmental factors whilst we did not identify strong direct effects of early life ses a single marker may not capture the downstream effects of inequality on numerous social economic academic and behavioural factors which can influence development of obesity over the life course adversity included prenatal exposure in the modern cohort and had direct effects on bmi therefore there is the possibility the cohort differences observed could be due to the earlier timing of the exposure and perhaps some in utero programming effects 42 the socioeconomic gradients in height were less prominent in the modern cohort a previous study comparing ntfs children and a later born newcastle cohort found that both had similar socioeconomic gradients in height 43 which when taken with our results suggests that socioeconomic height differences have narrowed since 1954 and possibly post1987 similar to our findings wright and parker did not find socioeconomic differences in childhood bmi between 1947 and 1987 in newcastle 48 however we observed socioeconomic differences in owob in the gms cohort suggesting socioeconomic inequalities on childhood owob have broadened over time 4 5 perhaps due to greater exposure to an increasingly obesitypromoting environment 64445 we did not identify socioeconomic differences in owob in ntfs which could be due to the low prevalence of owob and the time period postwar rationing permitted fairer distribution and consistency of resources which somewhat reduced class differences in nutrient intake and improved public health 48 perhaps explaining the similarities in birthweights and infant weights across deprivation indices in ntfs 43 these historical factors likely produced a more uniform pregnancy and early life experience and may explain why there were few early life exposures influenced by ses or associated with bmi in ntfs in this case from a developmental origins perspective the postnatal environment aligns with the prenatal anticipated environment in theory meaning appropriate adaptation and decreased risk of metabolic disease ie the predictive adaptive response 49 this is in contrast to findings in the modern cohort which may be a consequence of evolutionary and developmental mismatches and extensive environmental changes 50 examples include nutritional transition and changes to the food environment amongst the other lifestyle changes between 1947 and 2000 such as increases in the female labour force technological advances differing work practices and increased sedentary time and screen time 46 47 48 furthermore findings in gms may also reflect the cycle of higher birthweights and increased obesity across generations 15051 an important distinguishing feature of the historical cohort was the relatively low levels of owob although this meant it was not possible to estimate a multivariable owob model as the majority of ntfs children had a healthy bmi increases in bmi in this cohort may not necessarily have negative health effects however the higher prevalence of rapid infancy growth but lower levels of owob in ntfs is yet more suggestive of the implications of environmental changes similarly whilst it was not possible to adjust for all potential unmeasured confounders such as maternal bmi rapid infant growth remained a significant predictor in ntfs when there was lower prevalence of maternal obesity 52 the strengths of these cohorts is that they provide good coverage of the regional area and had rich prospective data collection study recruitment provided a representative sample of both locations at the given time as with most longitudinal studies there is attrition however as there were fewer advantaged families initially represented in the original gms cohort this bias resulted in a sample that is then more representative of north east england over time 53 although neighbouring areas newcastle and gateshead have some differences in social compositions and there will have been many other socioeconomic and environmental changes over 50 years apart from the onset of the obesity epidemic so we cannot assume that the differences observed solely reflect this aside from birthweight in gms the early life factors appeared independent of ses although this could be related to the socioeconomic measure used although the method used to classify deprivation between the studies was different registrar generals occupational social class was the only socioeconomic classification widely used at the time of the ntfs and townsend deprivation index was the only feasible means of comparing household deprivation in gms although the two might not be directly comparable when both have been used in other studies associations have been consistent across both measures and produced similar socioeconomic gradients in height 43 54 although anthropometric measures were utilised at age 9 to minimise the bias from puberty earlier onset of puberty can occur and some children may have been more developed 55 however earlier onset may be more likely in children with a higher bmi 5657 and so it may not be appropriate to adjust for pubertal status if bmi is causally related to early puberty 58 path analysis was utilised to model the relationships to examine the relative influence of each early life factors mediators and the indirect pathways to bmi however causal inference methods would be required to examine causality whilst early life rapid growth was an important factor there remained variation in childhood bmiz in those who had rapid growth in gms as many children with rapid infancy weight gain do not go on to have increased adiposity in childhood 31 further research is required to detect those most atrisk conclusion in conclusion analysis of two north east england birth cohorts born over 50 years apart demonstrated that children exposed to both socioeconomic disadvantage and the modern environments now have little evidence of growth restriction but a greater risk of owob rapid growth in infancy has remained a consistent antecedent of raised bmi but the association was stronger in the modern cohort which may indicate the effects are exacerbated by environmental changes online supplementary tables ethics approval ethics approval for both studies was obtained from the appropriate local research ethics committees and all participants gave their written informed consent

to determine whether the same relationships between early life risk factors and socioeconomic status with childhood bmi are observed in a modern cohort 2000 compared to a historic cohort 1947 the relationships between early life factors and ses with childhood bmi were examined in two prospective birth cohorts from the same region born 50 years apart 711 children in the 1947 newcastle thousand families study ntfs and 475 from the 2000 gateshead millennium study gms the associations between birthweight breastfeeding rapid infancy growth 012 months early life adversity 012 months and parental ses birth and childhood with childhood bmi zscores and whether overweightobese bmi 91 st centile using uk 1990 aged 9 were examined using linear regression path analyses and logistic regressionin the ntfs the most advantaged children were taller than the least 091 height zscore p0001 while in gms they had lower odds of overweightobese than the least 035 014 086 rapid infancy growth was associated with increased bmiz in both cohorts and with increased likelihood of overweightobese in gmsthis suggests that children exposed to socioeconomic disadvantage or who have rapid infancy growth in modern environments are now at lower risk of growth restriction but greater risk of overweight

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introduction there is a growing body of evidence globally of high levels of unmet reproductive and sexual health needs among women sex workers emerging research from lowand middleincome countries has demonstrated high rates of unintended pregnancies and poor access to contraceptives and other reproductive health services the data from higher income settings is sparse however recent research from canada found similarly low rates of access to sexual and reproductive health services including among pregnant and parenting sws high rates of unintended pregnancies alongside poor access to barrier and nonbarrier contraceptives for pregnancy prevention there is increasing global recognition of sexual and reproductive health inequities experienced by sws barriers to safely negotiating and using condoms reflects an important feature of those inequities and are largely attributed to structural factors particularly violence and threats of violence criminalization and stigmatization of sex work increasingly socioecological and structural determinants frameworks are being used to map how sws ability to negotiate health risks and protections are affected by structure including macrostructural factors community organization and work environment features concomitantly there has been a shift towards complementing existing biomedical and behavioural approaches with structural and communityled interventions that account for both proximal and distal structural determinants in shaping sws health outcomes though previous research on structural determinants has focused on venue and community empowerment interventions this has been almost exclusively drawn from lmic and to our knowledge only a handful of studies have examined the multiple influences of supportive workplace models and social cohesion on barrier contraceptives usage in vancouver canada despite the criminalization of sex work unsanctioned indoor sex work venues have long existed both as formalincall sex work establishments and informal or outcall indoor venues emerging qualitative and ethnographic studies in highincome settings have demonstrated that both social policy and physical features of indoor venues and social cohesion among sws may promote reduced violence and increase control over condom negotiation and use with clients while a handful of studies in lmic have examined social policy and physical features of indoor venues these have almost exclusively focused on hivpreventionrelated features and policies on hiv risk there remains a gap in the epidemiological literature on the influence of a broader range of workplace features including broader health care services access violence prevention measures and policies as well as their intersections on sws sexual and reproductive health practices given the absence of quantitative data on the influence of workplace models and social cohesion on sws condom use for pregnancy prevention particularly in high income settings this study aimed to 1 catalogue social policy and physical features of indoor venues to develop a safer work environment scale 2 to longitudinally evaluate the relationship between higher scores on the safer indoor work environment scale and social cohesion on sws condom use for pregnancy prevention in a prospective cohort of sws in vancouver canada methods study design data from january 2010 to february 2013 were drawn from a longitudinal cohort known as an evaluation of sex workers health access developed based on and monitored by a community advisory board of over 15 community and sex work agencies eligibility includes cisgender and transgender women that exchanged sex for money within the last 30 days in street indoor and online venues as described previously timelocation sampling was used for recruitment through day and late night outreach to outdoor locations indoor venues and selfadvertising spaces across metro vancouver sex work venues were identified through community mapping conducted with currentformer sws and are updated regularly by the outreach team a combination of outreach methods and contact by mobile phone and internet were used for followup consenting sws completed an interviewadministered questionnaire by a trained interviewer at baseline and semiannual followup together with an intervieweradministered nursing questionnaire on health and social supports the main interview questionnaire asks about individual interpersonal and sex work patterns work environment features and macrostructural factors the nursing questionnaire asks about experiences access and barriers to health and social supports including sexual and reproductive health all participants receive an honorarium of 40 cad at each biannual visit for their time expertise and travel the study holds ethical approval from the providence health careuniversity of british columbia research ethics board outcomesgiven previous research from this cohort documenting low use of modern contraceptives this study focused on condom use for pregnancy prevention the primary outcome was based on a yes response to male condom andor female condom to the question what type of contraceptives have you used for pregnancy prevention in the past month participants were asked list all contraceptives used in the last month which also included birth control pills depoprovera iud vaginal rings diaphragm spermicides emergency contraceptives or permanent contraceptives this outcome was timeupdated at every 6month followup primary exposure variable scale development and internal validity early formative and qualitative research with sws led to the inclusion of a diverse set of questions on the social policy and physical features of indoor work environments within the aesha questionnaire which were then catalogued to develop the safer indoor work environment scale to make use of longitudinal data all factors were considered as timeupdated variables at every sixmonth interview over the threeyear followup period based on the overwhelming distribution of responses to all questions favouring always or never item responses were dichotomized consistent with a structural determinants framework following factor analysis the indoor work environment features were grouped as follows 1 social and policy venuebased features which included supportive venuebased policies and managerial practices 2 physical venuebased features included access to sexual and reproductive health services supplies access to drug harm reduction servicessupplies and access to physical security features where relevant scale items were assigned scores based on a review of the literature from lmic indepth qualitative research conducted with aesha participants and consultations with the aesha staff and community partners work environment features found to be supportive of condom use was given a score of 1 vs 0 the descriptive statistics for each item including their distributions were examined exploratory factor analysis using varimax rotation was used to determine the number of factors present among the items using a maximum likelihood method factors were retained that had eigenvalues of greater than one collectively accounted for 7080 of the variance and preceded the elbow in a scree plot factor loadings were used to determine the number of items included within each factor additionally tucker and lewis reliability coefficient yielded a score of close to one finally latent class analysis cronbachs alpha and kuderrichardson scores were used to assess internal consistency within each subscale the final scale consisted of 19 venuebased items and is composed of five subscales social and policy venuebased subscalesws were asked if their indoor workplace had in place policies and managerial practices to support sws safety and control in negotiation transactions with clients displayed in table 2 physical venuebased subscalephysical venuebased subscale reflects three components a access to sexualreproductive health services and supplies b access to drug harm reduction services and supplies and c access to physical security features community organization and empowerment subscale lippman kerrigan and colleagues social cohesion scale was used to score the level of social cohesion among workers based on responses ranging from strongly agree to strongly disagree lippman kerrigan and colleagues social cohesion scale is described in detail elsewhere and has been previously adapted and validated with sws in lmic similar to work in lmic item responses to the presence of each indoor feature were summed for bivariate and multivariable longitudinal analyses a combined score for all venue subscales was created giving equal weight to each subscale the primary exposure variables were timeupdated at every sixmonth followup to account for changing work environments over time and their association with condom use for pregnancy prevention longitudinal regression analysesdue to low levels of missingness a listwise deletion approach was taken for missing data to determine if workplace features and community organization were independently correlated with sws condom use longitudinally multivariable analyses using generalized estimating questions were conducted a working correlation matrix was also used to help account for repeated measures by the same respondent over three years of followup a series of confounding models were constructed using an approach described by rothman and greenland for a total of six models confounders were chosen based on a priori knowledge of associations with condom use for pregnancy prevention and a statistically significant bivariate gee correlation with our outcome in addition variables were also considered confounders if they altered the association of interest by 10 all potential confounders were included in a full model backwards elimination was used to arrive at the final model sas statistical software package version 93 was used for all data analyses results sample characteristics of a total of 646 sws enrolled in aesha this analysis was restricted to 588 sws who had worked in indoor venues over the threeyear followup as the primary outcome was condom use for pregnancy prevention sex workers reporting sterilization were excluded the median age of the sample was 351 over onethird of women were of aboriginal ancestry and 236 were immigrantnew migrant sws primarily from asia overall 660 were visible minorities and 340 caucasian with approximately half of the participants having completed high school or some form of higher education while 455 of the sample intended on becoming pregnant over half also reported condom use for pregnancy prevention at baseline among the 374 women who used condoms all reported male condom use and 12 reported using female condoms as well all participants had complete data on work environment features and 102 were missing among the outcome though this did not vary between exposure and nonexposure groups table 2 describes the properties of the subscales of the safer indoor work environment scale which had satisfactory cronbach and kuderrichardson scores all subscales had cronbachs alphas scores of 085 indicating a high level of internal consistency there was one exceptionthe physical security features component of the physical venuebased subscale had a cronbach alpha of 0698 the cronbach alpha for the combined scale was 0914 work environment scores and condom use for pregnancy prevention in multivariable gee analyses increasing scores for all but one of the work environments were significantly independently correlated with increased odds of condom use for pregnancy prevention with every onepoint increase on the combined scale there was a 2 increased odds of condom use 101104 as displayed in table 3 the adjusted odds ratios aligned with increasing scores for each work environment subscale as follows managerial practices venue safety policies aor109 95 ci 101117 access to sexual and reproductive health services and supplies access to drug harm reduction services and supplies as well as lippman kerrigan and colleagues social cohesion scale access to physical security features was marginally associated discussion this study quantifies the relationship between intersecting social policy and physical venuebased features and social cohesion on sws condom use for pregnancy prevention the findings point to the role of venue and social cohesion in affecting sws sexual and reproductive health it also offers a multicomponent safer indoor work environment scale that can be used to measure the degree to which social cohesion combined with a broad range of venue features can create supportive or enabling environments conducive to sws health and safety this safer indoor work environment scale also has the potential to inform the development of workplace models that better support safer more supportive sex work models only a handful of studies have examined the more complex and intersecting influences of structural factors on sws condom use in particular studies from the dominican republic brazil china and the philippines have shown how workplace models that support hiv prevention including venuebased sexual health policies managerial practices and physical layout shape negotiation of hiv risk using the safer indoor work environment scale our study builds on these studies and demonstrates that alongside hiv prevention venue features and practices a combination of social policy and physical features that support broader sexual and reproductive health drug harm reduction and safety combined with higher levels of social cohesion among workers may increase sws condom use the implementation of venuelevel managerial practices and safety policies were independently correlated with sws condom use every onepoint increase in the social and policy venuebased subscale corresponded with a 9 increased odds of condom use similarly increased access to physical security features also enhanced condom use these findings likely reflect sws improved control over transactions reduced fear of violence and enhanced ability to negotiate for condoms by clients in venues that prevent violence through safety features policies and practices results from the current study also confirm findings from earlier qualitative research in this setting both in unsanctioned indoor venues within supportive womenonly housing and licensed health enhancement and massage parlour venues physical access to sexual and reproductive health services and supplies at a venue level was also directly correlated with sws condom use over a threeyear period other studies also have found evidence linking access to hiv prevention services and supplies and services to consistent condom use our research adds to this by demonstrating that it is the synergy of social policy and physical features at venues that promote sws condom use over time physical access to relevant services and supplies also may reflect important features of venuelevel social relations whereby sws managers and peers collectively support and facilitate condom use qualitative studies on sex work policies and management in india china and brothels in nevada also have reported that managers may represent important nodes for sti information and provide protection from violence contributing to increased condom use at the community level increasing scores for social cohesion among sws were positively correlated with increased condom use social cohesion has been described as a structural component of community empowerment which captures trust mutual aid and solidarity among sws the role of community empowerment and social cohesion on sws condom use has been well documented globally including in world health organization guidelines however these data are almost exclusively drawn from lmic such as brazil dominican republic and india these are settings where there has been significant investment in resources to support these features amongst sw communities such investments have not been nearly as prevalent in higherincome settings and point to an area where evidenceinformed investment in novel actions and supports for sw communities could be beneficial from a health and safety perspective only a handful of other studies have measured specific and intersecting facets of community empowerment most notably data from brazil and dominican republic and more recently swaziland moreover our results longitudinally demonstrate how a combination of social policy and physical venuebased and community organization characteristics can promote sws sexual and reproductive health finally increased access to drug harm reduction services and supplies was also associated with increased odds of condom use previous research has shown that among sws who use drugs increased control over drug preparation reduces sws risk of violence at the time of drug use and increases control over negotiation of both sexual and drug risks while substance use among streetbased sws and its association with inconsistent condom use have been documented our findings help to address an evidence gap regarding the potentially positive effects of drug harm reduction interventions on sws sexual and reproductive health drug harm reduction interventions and their apparent capacity to offer positive valueadded effects on the sexual and reproductive health outcomes of sws is a promising area of research and practice limitations as with all research with stigmatized and criminalized populations the clandestine nature of sex work makes identifying a sampling frame and randomly selecting a sample of representative participants challenging to address this limitation timelocation sampling and social mapping with team members were used that systematically sample sws at times and venues where they work additionally we did not measure consistencyfrequency of condom use and therefore cannot extrapolate these findings to hypothesize their effect on pregnancy outcomes or hiv transmission rates we were unable to assess sws relationships with their managers which has been documented as a key social and venue feature in other studies additionally we were unable to measure the influence of economic venuebased features on condom use together these features represent areas for research in future iterations of the scale as our analysis was focused on condom use for pregnancy prevention our outcome may not capture sws who consider condoms solely as a hiv prevention practice rather than pregnancy prevention method contraceptives and pregnancy can be a sensitive topic for already stigmatized populations and thus as with all selfreported data responses may be subject to social desirability bias there is a possibility of overreporting of condom use among sex workers in venues that encourage condom use with clients which may bias our results however given the studys protocols to ensure patient confidentiality and interviewers good rapport with participants this bias is expected to be minimal the interviewers also have strong community linkages with some having sex work experience themselves as well our study findings are specific to sws in a higher income setting but they underrepresent higher income sws in our setting therefore our study findings should be interpreted cautiously across sex work contexts conclusions this study is among the first to examine the longitudinal relationship of safer indoor work environments and social cohesion on sws condom use in a highincome setting the results provide key implications for future sexual and reproductive health policy and programming including hivsti prevention specifically this research highlights the role of venuebased policies and managerial practices as well as access to health and social supports on sws condom use for pregnancy prevention substantial evidence exists in canada and globally that criminalization and unsafe work environments reduce sws ability to safely negotiate condom use due to fear of violence and arrest safer indoor venues with supportive policies and practices together with strong policy support for sws to work collectively represent structural avenues through which to promote and protect sws safety and health furthermore these results suggest that even within contexts that feature substantial barriers for sws to access health care supportive sex workplaces may also help by providing such services themselves or by facilitating better access to appropriate supplies services and programs including condoms the whoun is calling for decriminalization of sex work globally in 2013 the supreme court of canada struck down sex work laws that prohibited working in indoor settings or the hiring or accessing of managers and others third parties such as security this study indicates that safer workplace models that include supportive venue and management practices are key to sws health and safety the evidence documented in the current study provides crucial insights to inform a new legalpolicy framework furthermore the findings shed light on how safer workplace models and the ability of sws to work together remains a critical conduit to promoting sws condom use • this study supports global calls for decriminalization to support the ability of sex workers to more formally collectivize and ensure access to safer work environment models that are essential in promoting condom use what is already known on this subject

backgroundthis study aims to report on a newly developed safer indoor work environmental scale that characterizes the social policy and physical features of indoor venues and social cohesion and using this scale longitudinally evaluate the association between these features on sex workers sws condom use for pregnancy prevention methodsdrawing on a prospective open cohort of female sws working in indoor venues a newlydeveloped safer indoor work environment scale was used to build six multivariable models with generalized estimating equations gee to determine the independent effects of social policy and venuebased features and social cohesion on condom use resultsof 588 indoor sws 636 used condoms for pregnancy prevention in the last month in multivariable gee analysis the following venuebased features were significantly correlated with barrier contraceptive use for pregnancy prevention managerial practices and venue safety policies adjusted odds ratio aor 109 95 confidence interval 95 ci 101117 access

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background summary cataloguing and explaining human cultural diversity has been a core question for many branches of the social sciences many evolutionary social scientists and behavioral ecologists posit that the patterns of cultural diversity observed around the globe are due at least in part to the physical and social ecologies individuals inhabit 1 2 3 for example in societies with a high pathogen prevalence cultures tend to be more collectivisticthis may be a strategy for dealing with high rates of disease through behaviors that protect the individual and the group from the threat of outside pathogens 45 higher levels of population density have been linked to lower rates of fertility 67 which may reflect an adaptive shift toward slower life history strategies in the face of stiffer social competition and societies that are afflicted with high extrinsic mortality threats tend to have stronger social norms which may increase the likelihood of survival in such conditions 8 although investigations of the interplay between ecology and culture have been fruitful most have focused on links between a single ecological variable and a single cultural outcome or small set of such outcomes additionally with some exceptions 7910 such investigations have focused on levels of those ecological variables at a single time point here we present the ecocultural dataset 11 which aims to address these limitations and spur future discoveries the ecd is a compilation of data from 220 countries on nine ecological variables and 72 cultural variables that are likely to be of broad interest to social scientists the countrylevel data in the ecd complements other comprehensive data sources such as dplace which focuses on smallscale societies 12 the ecd includes time series data on ecological variables and 11 statistical metrics for each designed to index properties such as historical averages variability across time predictability and extreme perturbations methods variable selection data were collected on the level of countries in constructing the ecd 11 we selected only variables that contained data from a minimum of twenty countries ecological variables although conceptualizations of ecology vary across disciplines 13 they generally share an emphasis on the relationships between organisms and their external environment 14 our conceptualization of ecology is largely grounded in behavioral ecology 15 and extends beyond the physical environment to include key features of the social environment as well which have been linked to adaptive responses across species such as population density and resource availability 2 this conceptualization of ecological variables encompasses environmental conditions that have direct implications for an individuals survival and reproduction which includes not only aspects of the natural environment related to climate but also factors like the availability and distribution of resources key to biological fitness we required that all ecological variables contain at least 20 time points for some number of countries to conduct a sufficiently powered time series analysis using the arima model we gathered data on nine different ecological variables rainfall temperature gdp per capita income inequality external mortality life expectancy disease threat population density and unemployment rates although these variables capture a wide range of features of the physical and social environment that may have consequences for human cultural variation we do not argue that this is an exhaustive set of variables which could be considered ecological cultural variables cultural variables were identified through reviews of the psychological literature and by crowdsourcing on social media and listservs from the psychology community to be included in the ecd cultural variables needed to be indices and to contain data for at least 20 countries in total this search yielded 72 cultural variables including values personality traits motivations social norms subjective wellbeing innovation and government functioning data usage and permissions ecological variables were collected from the world bank world health organization institute for health metrics and evaluation and scholarly publications these sources all permit the use of their data under the cc attribution 40 international license full sources are listed in table 1 cultural variables were collected from academic publications or publications by ngos intergovernmental organizations or other public facing data published online all of which is permitted for use with attribution the sources of all cultural variables used in the ecd can be found within the datafiles on osf metric calculation in addition to raw ecological and cultural data the ecd 11 includes 11 statistical metrics for each ecological variable to allow researchers to explore the relationship between timevariant features of ecological conditions and presentday cultural variation current levels mean across time extreme perturbations as well as indicators of trends variability across time and predictability we calculate these metrics for years ranging from 1950 to 2020 thus we calculated 99 different estimates of ecology for each country for which data was availableeleven metrics for each of the nine ecological variables autoarima mape and mase values were calculated using the autoarima function from the forecast package in r 16 a machine learning algorithm that fits models with various autoregressive integrated moving average parameters to a time series dataset and selects the optimal model based on fit we used a twostep traintest procedure in the first step autoarima was used to fit a model based on 80 of datapoints in the second step that model was fit to the heldout portion of 20 of datapoints we gathered three measures of predictability from these analyses mape and mase and firstorder autocorrelation data records all data is available on the open science forum at 11 1 ecd codebook contains the metadata for all ecological and cultural variables contained within the dataset including source whether the variable is a part of a larger taxonomy sample size when available and variable type 2 ecd data contains raw countrylevel data for nine ecological variables 72 cultural variables operationalizations and geographic metadata because this file presents time series data it is organized in the longformat such that every row represents a country and year with columns representing specific ecological variables if calculating correlations between an ecological variable and a cultural variable using time series data it is important to truncate the time series of the ecological variable to before the data collection of the cultural variable for example if correlating mean rainfall and agreeableness calculate a countrys mean rainfall from the first available date to 2007 which is the year of publication for the agreeableness variable not 2019 the last available year of data for rainfall technical validation the specific measures used to calculate the variables are available in their original source material the scales for the ecological variables are available in table 1 missing data are entered as na in the case of the codebook na under sample size indicates that there was no sampling or that the exact sample size is not provided it is worth noting that spatial and temporal autocorrelation are issues that researchers may encounter when using this dataset countries in geographical proximity should not be considered as independent datapoints due to high probability of shared ancestral history and horizontal cultural transmission 1718 further ecological data from two consecutive years are likely highly correlated given that it is rare for ecological conditions to drastically change from year to year and our ecological data is often averaged or collected at a single time point within a year spatial autocorrelation can be addressed in many ways including by conducting analyses within world regions or by using statistical approaches such as autocovariate models 19 temporal autocorrelation can be addressed through various methods for detrending time series data such as differencing or residualizing out linear trends and autoregressive components 1020 usage notes ecd can be used to explore theoretically and methodologically important questions about the ecology and human cultural universality and diversity by analyzing these data on their own or in concert with other sources of data researchers can explore questions including • how much of human cultural variation around the globe is explained by ecology 21 • how might interactions between different ecological variables andor their statistical metrics be linked to both specific cultural variables and patterns of cultural variation in general • are historical ecological conditions or current ecological conditions more closely related to cultural variation 21 • do different ecological metrics have qualitatively different linkages to cultural diversity 21 • how might interactions between different metrics of the same ecological variable be linked to cultural variation • how might interactions between certain ecological variables and cultural variables be linked to cultural variation • do societies cluster in a similar or different fashion based on different cultural variables • how might ecological similarity between home and host society predict relative ease or difficulty of acculturation illustrative exploratory analysis to illustrate one promising way in which these data can be used we explorevisually using dendrogramshow countries cluster based on cultural and ecological variables dendrograms are depictions of hierarchical clustering a statistical method for grouping similar observations within a dataset across multiple hierarchically nested levels the degree of similarity between two dendrograms can be assessed using bakers gammaa rank correlation coefficient with corrections for nonindependence of observations 22 or rather whether or not countries cluster at the same hierarchical level across two dendrograms as with a pearson coefficient bakers gamma values range from 1 to 1 we note that although dendrograms have been used in prior crosscultural work to explore clustering of countries 23 24 25 this approach is primarily used in an exploratory fashion as is the case in the present work thus the present analyses maybe better thought of as a jumping off point for further investigation rather than definitive findings we began by building a dendrogram using schwartz cultural values harmony embeddedness hierarchy mastery affective autonomy intellectual autonomy and egalitarianism 26 next we built a series of dendrograms representing the eleven different metrics for all nine ecological variables next we explored the clustering based on schwartz values and current levels of ecology as the latter metrics are most commonly used in crosscultural research in the dendrogram based on schwartz cultural values many western european countries are grouped together and are distinct from the clusters which contain the eastern european countries which is broadly consistent with previous research showing regional variation in values within europe 27 however there are some clusters in the dendrogram based on schwartz values that suggest cultural similarities which are not based on geographic proximity or other commonly used ways of grouping countriessuch as the purple cluster which contains romania venezuela japan brazil and the united states why might this be examining the current levels of ecology dendrogram provides some insight into this unintuitive finding for example brazil and the united states cluster closely together on the dendrograms for both schwartz cultural values and their overall current social and physical ecology additionally these dendrograms point to interesting avenues for future research by highlighting cases where ecological and cultural similarities diverge for example south korea and spain are in distinctly different cultural clusters but appear to have highly similar ecologies thus one avenue for future research might be to investigate which factors moderate links between ecological similarity and cultural similarity comparing the dendrogram built from current levels of ecology and schwartz cultural values yielded a bakers gamma of 026suggesting a moderate positive relationship between the two however not all metrics of ecology show the same relationship the bakers gamma comparing the schwartz dendrogram to the one for mape was smaller 004 for standard deviation it was larger 030 suggesting a greater degree of statistical similarity in the clustering of countries based on ecological variability and cultural values this range of bakers gammas suggests that the strength of similarity between ecology and culture can vary considerably based on which metric is used to measure ecology code availability all calculations were conducted in r 28 using the forecast psych foreign jtools and lmtest packages 16 29 30 31 32 the r code used to aggregate and calculate the statistical metrics of ecology is available on osf at code for the dendrogram example is also available on osf and uses the circlize and dendextend packages 3334 competing interests the authors declare no competing interests

scholars interested in cultural diversity have long suggested that similarities and differences across human populations might be understood at least in part as stemming from differences in the social and physical ecologies individuals inhabit here we describe the ecocultural dataset ecd the most comprehensive compilation to date of countrylevel ecological and cultural variables around the globe ecd covers 220 countries 9 ecological variables operationalized by 11 statistical metrics including measures of variability and predictability and 72 cultural variables including values personality traits fundamental social motives subjective wellbeing tightnesslooseness indices of corruption social capital and gender inequality this rich dataset can be used to identify novel relationships between ecological and cultural variables to assess the overall relationship between ecology and culture to explore the consequences of interactions between different ecological variables and to construct new indices of cultural distance

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in un sustainable development goal 36 to halve the number of global deaths and injuries from road traffic accidents car traffic is at the centre of this challenge not only do car occupants take 34 of registered road casualties car crashes are also a leading contributor to casualties in other categories like cyclists and pedestrians accordingly manufacturers and governments try to mitigate the risks of car driving with a host of safety equipment and legislation car safety is an important selling argument for many however in drivingas in lifeexperiencing risk can be the corollary of certain desirable states like excitement stimulation and exploration and rewards like gaining time thus various literature indicates that people have a preferred nonzero level of risk and will behave in a way that targets this nonzero level of risk for example during the covid19related lockdown increased speeding partially offset mitigated traffic accidents and mortality from reduced car traveling finding drivers of risk taking in driving and related behaviour constitutes important leverage to mitigating the societal and public health cost of car traffic literature proposes that stable personality factors or early age environment partially determine risk preferences however literature also mentions situational influences on drivingrelated risk taking car features for example influence intentions towards risky behaviour car size is a particularly important feature on the one hand people choose large cars because they see them as safer thus avoiding risk on the other hand large cars are much more likely to be involved in accidents implying their drivers take more risk here a question of direction of causality presents itself do people who seek more risk select bigger cars alternatively do bigger cars affect people so that they take more risk contributing to answering the second question is the aim of this report literature presents some indication that bigger cars positively affect peoples intentions to take risk but behavioural evidence is lacking cars have been getting bigger over the last decades and the market share of bigger cars has increased as car choice is typically subject to social norms and bandwagon effects the trend of increasing car size might proliferate bigger cars have more potential for doing damage in traffic thus any effect of car size on drivingrelated risk taking has important direct consequences on traffic safety moreover risk attitudes can affect risk taking across domains car size might therefore affect risk taking in a broad senseincluding in ways that feed back into traffic risk like is the case with substance abuse whether car size affects risk taking is therefore of substantial importance in a comprehensive approach to addressing road traffics societal cost and public health consequences in this report we provide theoretical and empirical evidence for the car cushion hypothesis the notion that bigger cars contribute to taking risk in and outside of driving contexts thus we hope to contribute to bases for interventions addressed at reducing the societal and public health cost of car traffic theoretical background the car cushion hypothesis and generalized risk taking in their seminal work hsee and weber find that higher levels of social connectivity can provide people with a sense of security that positively affects their risk tolerance in financial decisionsa mechanism they label the cushion hypothesis this hypothesis has roots in earlier findings that risk perceptionnot risk attitudedrives risk taking behaviour assessments of risk much more affect than cognitiondriven and risk tolerance is strongly related to feelings of control comfort stability and safety in the social domain can make one feel supported making risk in the financial domain look less daunting oppositely losing control in one domain affects subsequent financial risk taking and a focus on controlling loss affects risk taking across domains like health social settings ethics and gambling receiving physical touch affects financial risk taking highlighting the affective nature of risk processing similar to hsee and webers general cushion hypothesis we propose the car cushion hypothesis bigger cars provide people with a sense of security and control thatsimilar to other instances of safety and control will lead to more risk taking importantlyand similar to the cushion hypothesiswe propose that the effect of car size on risk taking affects risk taking in a general sense beyond the specific context of driving cars process evidence safety perceptions and regulatory focus we propose and test two kinds of process evidence first the notion that the car cushion hypothesis hinges on a feeling of safety security and comfort puts perceptions of safety central in the process of how car size affects risk taking thus we propose that this perception of safety mediates the effect of car size on risk taking second we build on regulatory focus theory to propose that the car cushion hypotheses finds boundary conditions in high promotion and prevention tendencies high scores on promotion focus reflect an aspiration for accomplishment associated with risk proneness high scores on prevention focus reflect seeking safety although of course oppositely related prevention and promotion tendencies operate to some extent independently therefore regulatory focus is measured as two separate subscales of promotion and prevention focus literature shows that these tendencies affect risk attitudes in traffic we propose that strong regulatory predispositionseither promotion or preventionreduce consumers sensitivity to context effects consumers that based on strong promotion tendencies seek risk will do so regardless of context similarly consumers who avoid risk based on strong prevention tendencies will do so regardless of context it is when regulatory tendencies are less pronouncedie at lower levels of promotion and preventionthat context effects can occur thus we propose that regulatory focus moderates the effect of car size on risk taking two experimental studies tested these inferences methodology and results study 1 the effect of car size on driving behaviour in this study we assess behavioural evidence of a positive effect of car size on risk taking in a driving context we collaborated with a belgian nonprofit that operates a fullscale realistic driving simulator developed by green dino1 for driver training we manipulated the size of the car that participants believed to be driving in reality we set the simulator with identical parameters between conditions the dependent measure was a composite measure of driving intensitycommonly related to crash risk we measured regulatory focus to assess whether the effect of car size on risk taking only occurs at low levels of promotion and prevention scores additionally we measured mood driving experience and attitude towards driving as covariates of our dependent measure driving intensity mood can influence evaluations of risk and we expected driving experience and attitude to make participants more risk tolerant considering the limited attainable sample size that results from the operational limitations of working with a car simulator we collected these covariates to reduce error variance and obtain a more accurate measurement of our hypothesized effects material and procedure participants were undergraduate students from a large european university part of a university subject pool for behavioural studies they came individually to a dedicated room at the university for a 20min session in return for a monetary compensation of 8€ candidates needed a valid drivers license to participate while the complex experimental procedure and limited availability of only a single driving simulator prevented us from collecting a larger sample of data a power analysis showed adequate power between 815 and 994 for the analyses below first participants learned about the procedure on a computer screen they were told that we were studying peoples driving behaviour in response to specific circumstances on the road we assessed participants driving experience and attitude and measured participants regulatory focus as two separate scales of promotion and prevention focus we also assessed participants mood based on the panas we then explained that the rest of this study would take place in the driving simulator and participants were at that point randomly assigned to the car size condition they were shown a picture of the car they would drive with the model name mentioned which was either a big car or a small car brand was deliberately kept constant and consistent with the layout of the interior of the simulator which showed the brand logo placed centrally on the steering wheel the last computer screen then invited participants to take place in the driving simulator the simulator asked participants to drive naturally throughout the session participants were first allowed a twomin practice drive they were then instructed to drive the car for 10 min along a predetermined route an average traffic density was simulated including other cars pedestrians and cyclists during this second drive the simulator measured speed in kilometres per hour acceleration and deceleration both as kilometre per hour squared and throttle and braking as percentage of full pedal articulation all sampled at five measurements per second after each ride the simulation software provided averages of these measures that constitute our dependent variables results and discussion because some of the driving parameters were a magnitude bigger than others we standardized all items before averaging them into a single measure of driving intensity neither mood driving experiences nor attitude led to any significant effects hence we did not include these variables for further analysis a first analysis revealed that the bigger car led to a higher driving intensity than the smaller car 226 p 0023 we found significant differences for most individual variables included in driving intensity except average speed and braking which show directional effects the two subscales of regulatory focusprevention and promotiondid correlate with each other but only weakly and testing internal consistency with reversed prevention items did not warrant aggregating all items into a single score so we used the subscales separately for the remainder of the analysis a general linear model analysis of the data yielded no threeway interaction between car type prevention and promotion analysing the effects of promotion and prevention separately we did find two significant twoway interactions that qualified the main effect of car type on driving intensity first we found a significant interaction between car type and promotion focus on driving intensity 436 p 0042 only participants low in promotion focus were sensitive to the effect of car type to examine this interaction in more detail we conducted a spotlight analysis at one standard deviation above the mean of promotion we found no significant difference in driving intensity between participants in the small car and those in the big car mirroring the previous result we found a near significant interaction effect between car type and prevention focus 309 p 0086 again we used spotlight analysis to find that at one standard deviation above the mean of prevention no significant difference appeared in driving behaviour between participants in the small car and those in the big car 070 p 049 at one standard deviation below the mean of prevention however participants in the big car seemed to drive more intensively 255 p 0014 only participants that scored low on prevention focus seemed to be affected by car type participants with high prevention focus drove cautiously no matter what car they believed to be driving when participants believe to be driving a bigger car this leads to more intense and risky driving behaviour these results provide initial support for the car cushion hypothesis moreover our results support that promotion and prevention focus can impose boundary conditions on this hypothesis in that consumers scoring high on either promotion or prevention focus are less susceptible to the context effect on which the car cushion hypothesis hinges study 2 the effect of car size on generalized risk taking study 2 aimed at replicating and extending the effect of car size on risk taking beyond driving thus we seek to find support for the notion that bigger cars encourage generalized risk taking we set up this second study as a scenario study with behavioural and consequential outcomes facilitating a bigger sample size to ensure robustness of findings material and procedure participants were subject pool members of the behavioural lab of a large european university who came to our behavioural lab in groups of eight and participated in return for a monetary base payment of 6€ candidates needed a valid drivers license to participate our manipulation comprised having participants evaluate one of two car ads randomly assigned between participants we asked participants to imagine they were in the market for a new car and asked to imagine considering the presented car as a candidate choice both cars were from the same brand to control for brandrelated associations the big car condition showed a mercedes rclass belonging to the mpv category while the small car condition showed a mercedes aclass belonging to the compact category despite their substantial difference in size these cars have several design elements in common we selected four images2 for each car of which three smaller ones from the press kit showing the car from a frontside angle from the back and from the side for each condition we added one larger image showing the car from a frontside angle driving with visible people inside for size reference as part of the manipulation we gave a short description of each car including for the rclass that it was the largest in its class for all your transportation needs and for the aclass that it was small and nimble for navigating the city we then asked participants to report their perception of the car on four items each rated on 7point likerttype scales after rating the car we told participants this part of the session was completed and asked them to move to the nextostensibly unrelatedtask comprising our dependent measure as a dependent measure we used the balloon analog risk task among attitudinal and behavioural measures of risk taking the bart has demonstrated itself to have high predictive validity for risk taking in natural settings including drug use unprotected sex gambling and stealing in the bart participants receive 5 cents for every time they push the button that pumps a balloon further but lose all of their money on a specific balloon if it pops thus every additional pump increases the total gain but also increases the risk of loss on a trial participants can cash out on a balloon if they do not want to take extra risk or give an extra pump to increase their outcome with the risk of popping the balloon participants repeated this task over 20 independent balloons we ensured incentive compatibility by randomly drawing one participant per session who won the money made in the task results and discussion following instructions on interpreting the bart we calculated the corrected average number of pumps for each participant which is the average number of pumps across balloons excluding balloons that popped car size affected the corrected average number of pumps 352 p 0001 perceptions of the cars differed significantly with the bigger car scoring higher on all dimensions to account for potential response bias we regressed the corrected average number of pumps on condition and the four perception dimensions only condition 219 p 0029 and perceived safety 216 p 0032 remained significant when including all these predictors we tested whether perceived safety mediated the effect of car size on risk taking a bootstrapping algorithm supported partial mediation with a significant indirect effect and significant direct effect we found no support for a similar mediating role of other dimensions these results highlight the cushion aspect of our theorizing in that perceived car safety stands out as best predicting generalized risk taking general discussion traffic in general and car traffic in particular place a heavy burden on public health car traffic is multifaceted including technical infrastructural societal and psychological aspects with the consumer central in this context addressing the societal and public health cost of car traffic requires that measures not just prove their individual effectiveness but are also evaluated for their interactive effects with other parameters of traffic situations especially regarding secondary effects on consumer behaviour the latter fully applies to car size from a technical perspective bigger cars are preferable because they protect their occupants better however they get into accidents more frequently and are a threat to all other road users and thus one consumers choice affects other consumers welfare the car cushion hypothesis we propose in this report contributes to this puzzle by showing that larger car size increases driving and nondriving related risk taking thus we find that a behavioural effect exacerbates a technical factor for large cars contribution to traffics societal and public health burden building on literature relating regulatory focus to trafficrelated risk attitudes our results also specify boundary conditions for this effect in that the effect is mitigated for consumers strongly occupied by regulatory promotion or prevention tendencies importantly the results of study 2 suggest the potential for broad behavioural effects and corroborate effects of safety cues on generalized risk taking reported in literature earlier a notable example is how bike helmet wear affects generalized risk taking and sensation seeking policy makers might want to look into the relationship between car size and risky choices that interact with driving like texting or substance abuse moreover behavioural effects might also spill over to contexts outside of the one containing the safety cue as an example of the latter literature reports that drivers of heavy goods vehicles often get into accidents shortly after leaving their vehicle and suggests that this is due to excessive risk taking caused by remaining safety feelings carried over from inside of the heavy vehicle from a theoretical perspective we contribute to the understanding of risk taking extending the cushion hypothesis to driving behaviour we provide process evidence showing moderation of the effect by regulatory focus and mediation by perceptions of safety moreover we contribute to a holistic theoretical lens on traffic safety where we look at the interactive effect of technical traffic parameters and human behaviour additionally our findings contribute to the question about the direction of causality of the relationship between car size on the one hand and risk taking and accident proneness on the other hand from a substantial perspective we aim for our results to inspire and give direction to public policy makers wishing to investigate design and implement measures aimed at reducing the societal and public health cost of traffic our findings indicate that incentivizing against larger cars might have the double benefit of reducing incidents as well as their severity several countries around the world use car size as a partial tax base while others give exemptions to smaller cars this makes sense since larger cars proportionally also lay larger claims on public infrastructure the netherlands taxes passenger cars based on their mass and literature shows this allows for full internalization of external costs of car mass based on our findings we argue for a broader adoption of car sizerelated tax bases in order to reduce the societal and public health impact of car traveling and absorb more of its external costs in the future autonomous vehicles might solve the driving behaviourrelated part of our findings nonetheless our finding that risk taking generalizes across contexts might mean the effect of bigger cars migrates to activities like extreme sports gambling substance abuse or other potentially harmful behaviours as we use a proxy of generalized risk taking rather than measure downstream risky behaviours directly our results should not be seen as conclusive we hope they highlight the importance of a holistic view on risk taking in traffic contexts and more particularly inspire future research into the relationship between car size and a broad range of specific risktaking instances to come to strongly supported and effective public policy measures in the interest of traffic safety data availability data available upon request

car traffic and accidents involving cars create an enormous societal cost particularly in terms of negative consequences for public health mitigating these effects is a daily concern for public and private institutions and people around the world at least a subset of accidents is attributable to the amount of risk drivers allow in their driving and in related behaviour like mobile phone use or substance abuse our study looks at the effect of car size on risk taking while literature highlights several behavioural effects of car size the direction of causality of these effects is not always clear and empirical evidence is lacking two behavioural and consequential studies support that car size affects risk taking in driving and that this increase in risk taking generalizes to other domains as well based on these results and in line with literature showing that social stability and security can affect financial risk taking we propose the car cushion hypothesis this hypothesis suggests that bigger cars make people feel more secure which affects their behaviour in terms of generalized risk taking we discuss policy implications aimed at contributing to reducing the societal and public health cost of car trafficaccording to the world health organization who 2018 135 million people lose their lives in traffic each year road accidents are globally the leading cause of death in the 529 age group and the eighth leading cause across all ages on top of casualties about 50 million people are injured in traffic every year next to this human tragedy the economic loss associated with traffic accidents is estimated at 012 of global gdp chen et al 2019 further contributing to the enormous societal cost of road traffic french gumus 2021 mitigating the human and economic cost of road traffic is a priority for the who expressed b claus

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national household surveys predominantly the demographic and health surveys which are mostly conducted once every 5 years this includes contraceptive use as well as sexual activity marriage and fertility the performance monitoring and accountability 2020 surveys provide an opportunity to intensify populationbased monitoring of trends in key asrh indicators through annual surveys while contraceptive use was the primary area of interest the surveys also collect data on multiple other indicators including fertility marriage sexual behaviour we assessed the extent to which the annual pma surveys contribute to monitoring of these asrh indicators by analyzing the annual data and comparing the results with the 5yearly demographic and health surveys in five countries during 20132018 ethiopia ghana kenya nigeria and uganda we assessed the trends and internal consistencies in sex marriage pregnancy and modern contraceptive use among adolescents in five countries we also assessed the external consistencies by comparing these data with dhs we focused on four current status indicators of asrh among girls 1519 years ever had sex currently married has given birth or currently pregnant and currently using modern contraceptives among sexually active unmarried girls in each country the dhs surveys sample sizes were larger than those of pma which could explain the reasons for lager survey design effects and confidence intervals in the pma surveys as compared to dhs the pma and dhs results on adolescent childbearing child marriage sexual debut and contraceptive use among unmarried sexually active adolescents were different in some countries however both surveys results highlight slow progress in adolescent and reproductive health indicators with major disparities between the countries we therefore conclude that since adolescent childbearing is an sustainable development goals indicator that should receive increased attention as one of the targets and indicators of the sdg in countries with limited research in adolescent sexual and reproductive data the pma surveys are potential data sources for periodic monitoring of adolescent sexual health outcomes and interventions however the internal and external inconsistency poses a concern on the reliability of the current surveys in the measurements of asrh indicators background adolescent sexual and reproductive health is a priority public health issue in many countries in subsaharan africa particularly for girls 12 poor access to modern contraceptives among adolescents in subsaharan africa may lead to adolescent pregnancies and related consequences such as early marriage school dropout and maternal and neonatal morbidity and mortality 12 early initiation of sex and low condom use in adolescence is associated with risks of hiv and other sexually transmitted diseases 1 2 3 these behavioural patterns have major consequences for adolescent health and development opportunities especially for girls whose human capital development is undermined 4 5 6 7 in most countries in subsaharan africa monitoring of asrh relies on national household surveys predominantly the demographic and health surveys which are mostly conducted once every 5 years 8 this includes contraceptive use as well as sexual activity marriage and fertility fiveyearly surveys generally should suffice for monitoring marriage sexual behaviour and childbearing unless rapid changes are expected contraceptive use may change more rapidly during major scale up of interventions and it has been argued that more intensive monitoring may benefit program implementation 9 the performance monitoring and accountability 2020 surveys provide an opportunity to intensify populationbased monitoring of trends in key asrh indicators as these surveys are conducted frequently pma 2020 was primarily created to provide rapid and frequent estimates of modern contraceptive use demand and supply in priority countries for the global initiative family planning 2020 which aims at a rapid scaleup of access to modern contraception 10 this monitoring effort in now more than ten countries included household surveys as frequent as once or twice a year while contraceptive use was the primary area of interest the surveys also collect data on other indicators including fertility marriage sexual behaviour the pma 2020 household surveys present a new approach in terms of its high frequency of implementation use of resident interviewers and administering a short facetoface questionnaire using smartphones or tablets details of the pma survey methodology including data collection processes are published elsewhere 10 the quality of the pma survey data on contraceptive use among all women of reproductive ages is considered satisfactory 10 also the use of a limited number of questions on recent births resulted in the only modest underestimation of fertility largely because of missing multiple births 11 in this paper we considered five countries that conducted pma 2020 and dhs surveys to assess the extent to which pma 2020 survey data are a useful addition for the tracking of asrh indicators we focused on the internal and external consistency of the trends in selected current status indicators of sexual debut marriage pregnancy and childbirth and contraceptive use among adolescent girls and ascertained trends to assess the valueadd of frequent household surveys for monitoring of selected asrh indicators methods we selected countries with at least 3 years of nationally representative rounds of pma surveys and two recent dhs surveys as of january 2020 five countries in subsaharan africa met these criteria for nigeria data for 2014 and 2015 were not considered as they were not based on a nationally representative sample we used the ipumspma database and the dhs archive to download all the datasets 12 the pma surveys and dhs both use multistage sampling in the selected clusters after listing the households within the cluster a fixed number of households are randomly selected and interviewed in the pma surveys the fixed number of households per cluster is typically 35 ranging from 33 to 44 13 since the pma surveys revisit the same cluster and households are randomly selected in each round within this cluster a repeat of respondents who have participated in the previous rounds is possible and this is recorded by the interviewers the pma2020 surveys collect data through female resident enumerators and unlike the dhs use the same enumerators in subsequent rounds equipped with a mobile device with uploaded shorter survey questionnaire that is used for facetoface data collection 14 both pma 2020 surveys and dhs collect information from eligible women aged 1549 who are either usual members of the household or slept in the household the night before the interview the sample size in pma2020 is powered to estimate the modern contraceptive prevalence rate among all women with a margin of error of 3 by sampling stratatypically urbanrural and in some cases aggregated administrative regions our analysis focused on four current status indicators among girls 1519 years • marriage the proportion of girls who were currently married divided by the total number of girls 1519 years • ever sexually active the proportion unmarried adolescent girls who have ever had sex within the last 30 days preceding the date of data collection • adolescent childbearing the proportion of girls who were pregnant on the day of the interview or who have ever had a birth among all girls 1519 years • contraceptive use the proportion of girls who are currently using modern contraceptives among all unmarried sexually active girls 1519 years there were no major differences between the questionnaire contents that were relevant to these indicators with one exception questions about childbearing in the dhs are asked as part of a full birth history while the pma2020 is limited to questions about the number of live births and the dates of the most recent births this may or may not include stillbirths in addition the dhs asks separately about live births and on stillbirths and abortions we examined the difference pma2020 conducted two surveys in the same calendar year in all five countries in 2014 and in kenya in 2015 we combined these two surveys into one because of three reasons the pma approach of having at least 2 rounds of the survey within the same years was discontinued from 2016 minimal changes within a year in the asrh indicators are expected and pooling the datasets increases the pma sample size for the estimation of annual changes in the asrh indicators we assessed the sample characteristics and composition of the pma and dhs surveys relevant to adolescents the analysis was done in stata 16 and ms excel for all indicators we computed standard errors with their respective 95 confidence for both pma surveys and dhs we also computed the survey design effects for pma surveys and dhs for each indicator this design effect referred to deff is the ratio of the actual variance over the variance of a truly randomized sample and is expected to be higher with a smaller number of clusters or with a greater intracluster correlation of the indicator of interest 1516 we also assessed the effect of repeated respondents by analysing the data with and without repeat responders to assess external consistency we used a difference of proportions test to assess the statistical significance of the difference between the pma surveys and dhs for the same country and year for each of the four indicators to assess internal consistency we analyzed pma surveys annual trends in the proportion of study indicators over time we tested for statistical significance of indicators trends over time for each of the data source we applied the same approach in the assessment of the differences between the 1st year of pma survey and last year of the pma survey at the time of this studys data analysis jontera userwritten stata command for testing the trends based on the jonckheereterpstra test 17 was used to test the significance of the trends for the difference between the data points we calculate the level of significance based on the data point standard errors we adjusted for populationweighted numbers in the analysis of indicators with the enumeration areas as the primary sampling unit results survey characteristics the number of dhs survey clusters was at least three times higher than those of the annually pooled pma surveys in each country the number of female respondents 1519 years was at least two times higher in the dhs than in the pma surveys except in ghana the proportions of adolescent girls in both surveys about 20 of all women of reproductive ages were close in both survey types and varied little over time we also checked for the response rate for and we found that the response rates for each of the asrh indicators were at least 95 in both surveys for instance sexual debut response rate was at least 95 and 99 the pma survey in each country for each of the survey round and in the dhs in each country for each of the survey wave respectively the proportion of adolescent girls who had previously participated was variable between countries and pma surveys it was as high as 265 in ghana in 2015 but less than 10 in nine of the 22 pma surveys we examined the effect of repeated respondents in the pma surveys on the sexual behaviour indicator by excluding and including the repeated respondents but observed very small absolute changes in the indicator less than 1 in all surveys except ethiopia 2015 and kenya 2017 the survey design effects were only slightly larger in the pma surveys than in the dhs the pma deff relative to dhs deff was between 09 and 20 adolescent childbearing and pregnancy figure 1 presents the percentage of girls 1519 years that ever gave birth or were currently pregnant in the pma surveys and dhs with 95 confidence intervals the direct comparisons between the pma survey and dhs conducted in the same year show that there was little difference in kenya and ethiopia the absolute percentage point differences were larger and statistically significant in uganda nigeria and ghana the trends in the pma surveys in ethiopia suggest no change over time the pma surveys show an irregular trend in uganda and ghana though none of the pma surveys differed significantly from the preceding year overall we observed a decrease in the pma surveys in nigeria with a 6 decline observed between 2016 and 2018 the nigeria dhs also showed a slight decline between its last two surveys but the inconsistency in levels between the two surveys is large kenya is the only country showing a consistent downward trend over time with a decline from 20 to 2014 to 13 in 2018 details on the pma and dhs estimates are indicated in additional file 1 table s3 for childbearing it has to be kept in mind that the pma surveys and dhs have slightly different questions the potential size of this difference was assessed in the dhs the absolute difference between the proportion of adolescent girls who had ever given birth to a live child and the proportion who had a child or stillbirth or abortion was 03 in kenya dhs 2014 05 in ethiopia dhs 2015 11 in nigeria dhs 2018 15 in uganda dhs 2016 and 23 in ghana dhs 2014 the pma surveys ask only for births and may have captured some of the stillbirths but would generally be expected to be only slightly lower than dhs marriage figure 2 presents the trends in the percentage of adolescents who were ever married at the time of the interview in the pma surveys and dhs with 95 confidence intervals the direct comparison between the pma survey and dhs conducted in the same year shows that there was little difference in kenya and ethiopia the absolute percentage point differences were large and statistically significant in uganda nigeria and ghana the pma trends in ethiopia and uganda suggest no change over time in ghana the pma surveys show an irregular trend though none of the surveys differed significantly from the previous year overall a downward trend was observed in nigeria with a 7 decline in the pma surveys between 2016 and 2018 in kenya we observed consistent downward trend over time with a decline from 13 to 8 during 20142018 details on the pma and dhs estimates are indicated in additional file 1 table s4 ever had sex for the percentage of unmarried girls who had ever had sex at the time of the interview the direct comparison between the pma survey and dhs conducted in the same year shows that there was little difference in ethiopia the absolute percentage point differences were large and statistically significant in uganda in 2016 kenya in 2014 nigeria in 2018 and ghana in 2014 overall we did not observe significant changes in the trend for kenya ethiopia nigeria and ghana in uganda an upward trend was observed from 35 to 2014 to 41 in 2018 details on the pma and dhs estimates are indicated in additional file 1 table s5 modern contraceptive use among sexually active adolescents figure 4 presents the trends in the percentage of unmarried sexually active adolescents who were using modern contraceptives in the pma surveys and dhs the direct comparison between the pma survey and dhs conducted in the same year shows that there was a large difference in kenya and to a lesser extent in nigeria and ghana differences were small in uganda and ethiopia no significant changes over time were observed in uganda and ethiopia however the rates increased by 12 in uganda between 2014 and 2018 from 14 to 2014 to s6 table 2 is a summary of findings for consistency between pma survey and dhs and trends of the respective asrh indicators by country based on statistical significance discussion the analysis of pma and dhs surveys in five countries suggests that the pma surveys are a welcome addition for the monitoring of asrh indicators but the large and inconsistency sampling errors between surveys that affect trend analysis are a challenge in several countries the measure of inconsistency alone may not decisively determine the reliability and validity of the survey however using multiple approaches we compared the data collection tools and results on asrh indicators of the two surveys first we considered the survey characteristics pma surveys used similar survey questions as the dhs for the topics considered here and where there were differences the impact on the results was small the reinterviewing of respondents did not influence the results pma surveys rely on smaller numbers of clusters and smaller sample size than dhs which resulted in a larger survey design effect and larger sampling errors the sample compositions in terms of representation of adolescents were similar between pma surveys and dhs we also found that the age composition by single years within the 5year age group varied little and that therefore age standardization had little impact on the results for the indicators therefore we can conclude that the survey compatibility is good and pma surveys though smaller in size provide results that are comparable with dhs the pooling of survey years for pma surveys may help reduce the sampling errors second the comparison of the results for each indicator for the pma survey and dhs conducted in the same year showed good agreement in ethiopia for all indicators and in kenya for all except sexual debut and contraceptive use for the other three countries however there was a significant difference between the pma surveys and dhs for all indicators except family planning in ghana the patterns of the differences vary for instance in uganda three of the four indicators were significantly higher than the dhs while in ghana the reverse was the case in general the pma surveybased trends were similar to the trend in the last two dhs but in some countries like nigeria the levels were very different we can conclude that there often are important differences in the results on prevalence for all indicators and that these differences are country specific as they occurred consistently in the three of the five countries and not in ethiopia and kenya this does represent a challenge for the assessment of levels but the greater consistency for the trends than for levels is important and allows more accurate estimation of levels and trends using all data sources third to assess the added value of frequent national surveys we reviewed the country trends over time from the pma surveys and all surveys rounds if the trends were highly irregular or there is little evidence of changes over time the added value of annual surveys for monitoring was considered limited in seven of the 20 countryindicator pairs there was consistent evidence of changes over time including child marriage and adolescent fertility in kenya and nigeria and sexual debut and family planning use in uganda even though highfrequency surveys are more useful for indicators that can change rapidly than for indicators of behaviour such as marriage sex and childbearing in adolescence which tend to change more gradually we did not find consistent evidence to support this the large sampling errors in the annual surveys are a likely contributor our findings are consistent with earlier assessments of the data quality and added value of pma surveys on contraceptive use 10 and fertility 11 the surveys provide a wealth of information on in this case asrh indicators which allow more frequent tracking especially when used in combination with dhs results the surveys are however smaller in terms of numbers of clusters and sample size and disaggregation by subnational areas or wealth quintiles including other stratifiers could be problematic the added value for monitoring indicators of sexual behaviour marriage and childbearing lies primarily in adding to the volume of data generated in countries through multiple survey platforms pooling data sets will allow for greater disaggregation given the relatively slow change of these culturally engrained asrh behaviours related to sex marriage and childbearing it appears that annual monitoring would add only limited value also given the sampling errors and observed differences between surveys this however would be different for indicators such as contraceptive use which could change more rapidly the utility of annual surveys would then be determined by expected annual changes related to the level of program effort despite the internal and external inconsistencies our analyses confirm that asrh remains a critical issue for girls in the five countries in subsaharan africa based on the pma annual estimates sexual debut in adolescence is common and not decreasing with 3040 of 1519yearold single girls reporting to have started sex in four of the five countries while the current use of modern contraceptives among unmarried adolescent girls remained low and puts girls at risk of pregnancy and sexually transmitted infections low use of modern contraceptives among unmarried adolescent girls especially condoms has been raised as a major issue for asrh programs 18 furthermore child marriage and adolescent childbearing continued to be common in all countries affecting 1025 and 1030 of girls respectively in the most recent pma surveys and only in kenya and perhaps nigeria there was evidence of a decline of both indicators there are striking differences between the five countries at the one end uganda stands out with close to 30 of girls 1519 who are pregnant or have begun childbearing compared to only 10 in the other four countries according to the most recent pma survey also the proportion married and early initiation of sex is greater in uganda than in the other countries ethiopia is at the other end characterized by low sexual activity among unmarried adolescent girls low levels of adolescent childbearing and high levels of child marriage the contraceptive use among unmarried sexually active adolescents close to 50 in ethiopia compared to 25 in ghana and uganda and 35 in kenya and nigeria the kenya pma surveys provide the greatest evidence of a decline in asrh indicators of sexmarriage and childbearing nigeria shows an improvement in several asrh indicators while ghanas trend data the most irregular of the five countries present no evidence of positive changes adolescent childbearing is an sdg indicator which should receive increased attention as one of the targets of the sdgs but the evidence of positive changes is modest limitations our analysis is based on data from five countries and may not capture the potentially larger variation between surveys in other country situations with different patterns of asrhrelated behaviours pma 2020 surveys have now expanded to 11 countries which open the possibility to conduct further comparative analyses provided dhs or other surveys are available the five countries used for our analysis also present extremes of a wide spectrum of asrh patterns in subsaharan africa as shown in a paper by melesse et al in the supplement the observed differences between the pma surveys and dhs results in some of the countries are not due to sampling errors alone but also survey implementation design issues or other issues that were beyond the scope of this study dhs and pma survey data on asrh are based on recall of selfreported behaviour collected through faceface interviews such data could lead to nonsampling biases and thus affect the survey results and such could perhaps explain the differences between the dhs and pma estimates despite the high response rates we know that the accurate reporting of premarital sex premarital pregnancies and marriage depend on context culture confidentiality legal and moral norms as well as survey characteristics such as interviewer characteristics and training length and structure of the questionnaire 1920 studies have indicated that the behaviours that are in contrast to widespread of social norms and regulations may be underreported 2122 particularly for the interviews that are conducted facetoface or those that may reveal the respondents identity 2324 a pma report on the methodological issues related to the reporting of the sensitive behaviours indicated that there were some inconsistencies in the reporting of the questions such as the number of births 14 which may affect the adolescent pregnancy or birth estimates of such indicators additionally marriage and union formation are often not single eventsand because of the legal cultural and regional attached to such events such may lead to underestimation if other aspects like cohabiting or living with a partner like you are married are not captured such factors may generate socially desirable responses rather than accurate information 2526 and thus leading to underestimation the misreporting arising from such could be more prevalent among adolescents who are not yet comfortable with their sexuality 25 because of the societal perceptions and legalities around early sex the issue of greatest concern is the underreporting of events a study that compared the same pma survey and telephone interviews respondents on the estimation of modern contraceptive prevalence indicated significant differences with the telephone interviews indicating higher estimated 27 in addition to ensuring privacy and confidentiality during interview other innovation approaches such as computer assisted interviews and confidential voting interviews 23 28 29 30 that have been applied to reduce social desirability bias should be considered for such sensitive questions in general our study did not result in the identification of possible structural differences in the nonsampling biases between dhs and pma surveys in the three countries with significant differences between the two surveys the direction of the difference varied by indicator and by country but no clear pattern emerged conclusions this study contributes to the literature on the reliability of the available data sources in the measurement of asrh indicators for girls and how these data could be used to monitor trends the internal inconsistencies in the asrh changes in the pma surveys and external inconsistencies in some of the countries presents a concern on the reliability of the available data in estimating asrh indicators further the small samples may also make it impossible for the examination of the distribution of asrh indicators across stratifiers eg socioeconomic characteristics and further data pooling should be considered to overcome this challenge despite the differences between pma 2020 surveys and dhs surveys conducted in the same year and inconsistencies of the pma survey time series for several indicators in some countries we found no systematic issues with pma surveys and consider pma surveys a valuable data source for the assessment of levels and trends of asrh beyond contraceptive use and family planning for indicators of fertility marriage and sex among adolescent girls in subsaharan africa abbreviations funding the countdown to 2030 for womens childrens and adolescents health is the recipient of an investment of the bill melinda gates foundation this study also benefitted from funding of canada partnership for womens and childrens health the contents of this research article only reflect the authors opinions but do not show interests of either of the organizations involved in the funding consent to publish not applicable competing interests the authors declare that they have no competing interests • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

the annual collection of fertility marriage sexual behaviour and contraceptive use data in the nationally representative rounds of performance monitoring and accountability pma surveys in subsaharan africa may contribute to the periodic monitoring of adolescent sexual and reproductive health asrh however we need to understand the reliability of these data in monitoring the asrh indicators we assessed the internal and external consistencies in asrh indicators in five countrieswe included countries with at least three nationally representative rounds of pma surveys and two recent dhs ethiopia ghana kenya nigeria and uganda our analysis focused on four current status indicators of asrh among girls 1519 years ever had sex currently married has given birth or currently pregnant and currently using modern contraceptives among sexually active unmarried girls we compared the pma survey and dhs data and tested for statistical significance and assessed trends over time using jonckheereterpstra test statistic results pma and dhs survey methodologies were similar and where there were differences these were shown to have minimal impact on the indicator values the comparison of the data points from pma and dhs for the same years showed statistically significant differences in 12 of the 20 comparisons which was most common for sexual behaviour 45 and least for contraceptive use 25 this is partly due to larger confidence intervals in both surveys the time trends were consistent between the annual pma surveys in most instances in ethiopia kenya and nigeria but less so for ghana and uganda however both surveys highlight slow progress in adolescent and reproductive health indicators with major disparities between the countries conclusions despite the differences between pma 2020 surveys and dhs surveys conducted in the same year and inconsistencies of the pma survey time series for several indicators in some countries we found no systematic issues with pma surveys and consider pma surveys a valuable data source for the assessment of levels and trends of asrh beyond contraceptive use and family planning for indicators of fertility marriage and sex among adolescent girls in subsaharan africa

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introduction relationships with children impact parents psychological wellbeing yet despite the fact that the parentchild tie extends into both generations midand later life the vast majority of research in this area focuses on the consequences of having minor children on young adult and midlife parents psychological outcomes studies on the effects of the adult childparent tie and parent wellbeing tend to be crosssectional background and literature review theorizing adult childparent social support and strain and parent psychological distress research on the adult childparent tie and parents health has focused on the association between the presence of social support and strain and parents general wellbeing although increasingly research has explored other avenues of the parentchild tie including ambivalence and favoritism a lifecourse approach suggests that social support and strain shape the psychological wellbeing of parents due to the linked nature of parents and childrens lives support from adult children serves as a stressbuffering resource for aging parents across the life course which is in turn linked to psychological wellbeing at the crosssectional level parents with greater emotional support from adult children experienced increased life satisfaction decreased psychological distress and decreased loneliness parents who received generalized caregiving from adult children experienced a boost in psychological wellbeing less supportive and more strained parentchild ties have been associated with worse psychological health among parents for example koropeckyjcox show that at the crosssectional level parents with less social support and more strain in adult childparent relationships had higher rates of depression and loneliness while parents who reported being distant from an adult child had lower levels of happiness negative treatment from adult children was associated with more depression over time umberson similarly found that strain between parents and children is more influential than social support between parents and children on both generations psychological distress notably these studies are crosssectional and cannot ascertain casual processes nor look at change over time based on this body of crosssectional research we predict hypothesis 1 higher levels of social support and lower levels of strain from adult children at baseline will be associated with lower levels of psychological distress at baseline and over time theorizing parental dissatisfaction and parent psychological distress parental dissatisfaction may also impact parents psychological distress previous research conceptualizes parental dissatisfaction with an adult child in three primary domains dissatisfaction with being a parent feeling bothered as a parent and dissatisfaction with how a child turned out dissatisfaction with the parental role is important among parents of minor children but this has not been consistently tested among parents of adult children dissatisfaction for how an adult child has turned out is the site of a much larger research area in crosssectional studies parents whose child had more perceived problems had worse psychological wellbeing including life satisfaction depression and anger crosssectional studies show that dissatisfaction regarding adult childrens failure to achieve normative adult statuses was strongly linked to parental distress however how these processes operate over time with longitudinal data across the life course has yet to be fully addressed taken together we predict hypothesis 2 higher dissatisfaction with adult children will be associated with higher levels of psychological distress at baseline and over time theorizing adult childparent equity and parent psychological distress unbalanced social exchanges increase depressive symptoms and psychological distress this is likely because inequity reveals the unequal need for social support and thus hardship and unequal exchanges also rebuke norms of reciprocity a growing number of studies show that unequal exchanges with adult childrenespecially when children provide more supportare associated with decreased life satisfaction loneliness and increased depression in parents other studies using data on general networks that included but do not uniquely test relationships with adult children show it is more beneficial to give rather than to receive support from network members perhaps because receiving support entails the need for support while giving support provides a sense of purpose and service to others thus parents who receive high levels of social support but do not give social support to adult children in an equitable exchange may experience increased psychological distress on account of such inequity notably however studies addressing this question are not population based tend to be based on convenience samples and do not specifically test the adult childparent tie therefore they are unable to address causal processes through which equity may directly affect parents psychological distress given this body of work we predict hypothesis 3 equity and parents provision of more social support than they receive will be associated with lower levels of psychological distress at baseline and over time and parents receiving more than they give will be associated with greater parental psychological distress the gender of the parent a lifecourse approach emphasizes that the relationship between the intergenerational tie and parents psychological distress likely varies by social position including gender psychological distress varies at least in part by gender wherein women experience greater psychological distress than men moreover social strain support equity and parental dissatisfaction all appear to differ to at least some extent by gender mothers report closer and more conflictual relationships and lower levels of dissatisfaction and equity with adult children moreover adult childparent ties appear to be more salient to womens sense of self across the life course wherein being treated negatively by an adult child is related to higher rates of anger only among mothers we build on this body of research to hypothesize hypothesis 4 compared with fathers mothers with lower social support higher dissatisfaction and strain with adult child or less equity in the adult childparent relationship will have higher levels of psychological distress at baseline and over time methods we analyzed data from the first four waves of the americans changing lives panel study multistage stratified area probability sampling was used to obtain the original sample of individuals in the contiguous united states facetoface structured interviews lasting approximately 90 min each were conducted with individuals in 1986 1989 1994 and 2001 in the original sample 2204 parents of adult children were interviewed because one of the independent variables parentchild relationship equity was only asked in wave 2 we dropped those who did not respond to wave 2 which left 1757 individuals further restricting the sample to those without missing dependent variables or independent variables yielded a sample of 1692 parents among which 397 have two waves of answers 512 have three waves and 783 have all four waves measures psychological distress measured from wave 1 through wave 4 was defined as an unpleasant subjective state that included feelings of depression and anxiety psychological distress was based on an 11item version of the center for epidemiological studies depression scale the cesd scale was created from the following items for which respondents were asked how often you felt that way during the past week i felt depressed everything i did was an effort my sleep was restless i was happy i felt lonely people were unfriendly i enjoyed life i did not feel like eating my appetite was poor i felt sad i felt that people disliked me i could not get going for each item respondents chose answers from hardly ever some of the time and most of the time all 11 items were standardized using wave 1 weighted means and standard deviations before being combined by the acl researchers given the highly skewed distribution of the depression score we further computed the responses as the natural log of the mean score of cesd scores plus 3 to avoid the log of zero creating cesd scores with higher values denoting higher levels of psychological distress because the small numbers of the logged scores led to small regression coefficients that are inconvenient for interpretation we multiply the mean scores by 100 alpha reliabilities ranged from 82 to 83 across all four waves of the survey child social support and strainchild support was a latent variable composed of 2 items based on two questions in wave 1 think about your who 16 years old or older how much does your child make you feel loved and cared for how much is heshe willing to listen to your worries or problems child strain 1 was a latent variable constructed from two questions in wave 1 how much do you feel your child makes too many demands on you how much is heshe critical of you or what you do the answers for both child social support and child strain were reverse coded combined and imputed by the acl researchers so that higher values in the scale indicate higher levels of the intended construct parental dissatisfaction is also a latent variable constructed by the acl researchers it was based on three questions in wave 1 at this point in your life how satisfied are you with being a parent how often do you feel upset or bothered as a parent how happy are you with the way your turned out to this point answers in were reverse coded and combined with answers in and so that higher values in the scale indicate higher levels of parental dissatisfaction these dimensions of dissatisfaction address both dissatisfaction with ones parent role and dissatisfaction with a childs choices and behavior relationship equity was based on one question in wave 2 right now would you say you provide more support advice and help to your is it about equal or provide more to you we used the category of child provides more as reference group and construct two dummy variables for the other two categories interactions with genderwe generated interaction terms for each independent variable with the respondents gender sociodemographic covariateswe controlled for age gender education and income in all analysis we incorporated measures for age of the respondent at wave 1 and reported functional health index at each wave which allows us to account for functional limitations and impairment that may be associated with both the parentchild tie and parents psychological distress the functional health index was based on four sets of questions of whether and to what extent the respondents have difficulty engaging in the following activities because of their health bathing climbing a few flights of stairs walking several blocks and doing heavy work such as shoveling snow or washing walls around the house the acl researchers combined and imputed the index and we reverse coded it so that higher values in the scale indicate higher levels of functional health impairment we also controlled for other sociodemographic covariates that were relevant to parentchild relationship these covariates included gender marital status education measured in number of years completed at wave 1 total family income and number of children the sociodemographic covariates were mostly time invariant in nature for the population under study thus we did not include the timevarying controls in the analysis models controlling for race revealed similar findings as those presented in the article table 1 presents weighted means and standard deviation for all variables in the analysis analytical approach we used latent linear growth curve models to estimate the effects of independent variables on parents psychological distress at baseline and over time growth curve models recognize that parents have different levels of psychological distress at the baseline and these parents also experienced different rates of change in psychological distress as a function of their relationships with their adult children as a result growth curve models are able to predict trajectories of psychological distress as well as the dynamic linkages between parentchild tie and psychological distress over time growth curve models were appropriate for our analysis because of their ability to distinguish two levels of heterogeneity in estimating changes in psychological distress influenced by other variables the equations of the linear growth curve model were as follows all models were estimated using stata mixed with maximum likelihood estimation which allowed us to incorporate all respondents who have been observed at least twice including those who died during the survey period in the sample we also accounted for differential rates of dropout and death attrition by controlling for the number of participated waves and whether respondents died during the study period for example among those who died before wave 3 we used their answers for the first two waves control for the two participated waves and generated a dummy variable to account for their death in the survey period we present models without the random effects of attrition from those who dropped out or were deceased because these models did not improve the model fit the focus of this study was on estimating the effects of parental dissatisfaction and parentchild relationship equity on the baseline level and rate of change in psychological distress over time in analysis not shown we also explored whether parental dissatisfactionparentchild relationship equity functions as moderators that altered the relationship between child supportstrain and psychological distress but we found few significant results and thus do not include them in this article results descriptive statistics table 1 shows means or percentages for all variables as table 1 indicates the average age of the parents was 57 years at wave 1 and 68 years at wave 4 the majority of the respondents were female and married at wave 1 on average parents in the sample had 12 years of education 28531 dollars of family income and three children by wave 1 supplementary analysis showed that fathers in the sample were more likely to be married and they had more family income than the mothers on average mothers in the sample reported higher levels of functional impairment and higher psychological distress than the fathers across all waves mothers in the sample also reported more social support from children a greater likelihood to receive than give in relationships and higher parental dissatisfaction than fathers at wave 1 supplementary analysis show that those who did not complete all waves of survey tend to be older and unmarried and they had fewer years of education less family income and higher levels of functional impairment than those who completed all surveys those who dropped out also had higher levels of psychological distress across all waves but less child strain and less parental dissatisfaction at wave 1 than those who completed all waves of data collection consistent with previous research results from unconditional growth models with no covariates indicate that psychological distress decreased over the study period growth curve results table 2 shows results from the growth curve analysis demonstrating the estimated effects of the adult child support and strain parental dissatisfaction and reported equity measures and other covariates at the baseline level in addition to the rate of change in psychological distress over time social support and strain from children and psychological distress table 2 shows results from growth curve models that estimated the effects of adult child social support and strain on parents trajectories of psychological distress controlling for all sociodemographic covariates we included both social support and strain in the same model because testing them independently yielded the same results in model 1 the significant coefficient of 3953 shows that baseline support from adult children was negatively associated with baseline psychological distress results in model 1 show no significant effects of baseline support from adult children on the rate of change in parents psychological distress model 1 further indicates that baseline strain from adult children was positively associated with baseline psychological distress because the psychological distress declines over time in the unconditional growth curve model the significant negative coefficient of 0172 indicates that every oneunit increase in baseline strain increased the rate of decline in psychological distress by 0172 units however the significant coefficient of the slope for parent strain disappeared in model 2 when parental dissatisfaction index was added suggesting that the effect of parent strain on the rate of change in parents psychological distress was spurious because it could be explained by factors such as parental dissatisfaction in the analysis not shown we also examined how change in child supportstrain from wave 1 to wave 2 influenced the baseline level and rate of change in psychological distress over time yet we found few significant results parental dissatisfaction model 2 of table 2 added the parental dissatisfaction index to test how satisfaction in ones adult childparent relationship shaped trajectories of change in psychological distress in model 2 of table 2 controlling for all covariates baseline parental dissatisfaction was positively associated with baseline psychological distress moreover the significant negative coefficient for baseline parental dissatisfaction on the rate of change in psychological distress indicates that every oneunit increase in baseline dissatisfaction increased the rate of decline in psychological distress over time by 0189 units parents with higher dissatisfaction thus experienced a steeper declining trajectory of psychological distress than those with lower dissatisfaction as shown in figure 1 parents who started with higher rates of dissatisfaction at baseline experienced more psychological distress at baseline even though more dissatisfied parents experienced a more rapid decrease in psychological distress than the less dissatisfied parents they still experienced higher psychological distress over time because they began with much higher levels of psychological distress equity model 3 of table 2 as well as figure 2 shows results from growth curve models that estimated the effects of reported relationship equity between parents and adult children on parents trajectories of psychological distress controlling for all sociodemographic covariates results indicated that parents who offered more help than or the same amount of help as their children offer them had lower baseline psychological distress than those who received more help from adult children the significant positive coefficients for baseline relationship equity on the rate of change in psychological distress indicated that offering more or equal help to adult children in the baseline slowed the rate of decline in psychological distress over time by about 0758 or 0666 units than receiving more help from adult children moreover although those parents who received more help than they gave at baseline experienced a more rapid decrease in psychological distress over time they still have more psychological distress over time because they begin with much higher levels of psychological distress due to relationship inequity parents who offered more or similar amount of help to children had similar baseline psychological distress at baseline and over time gender interactions table 3 shows results from growth curve models that examined whether parents gender moderates the relationships between the parentchild tie and psychological distress we added gender interaction terms with each predictor and found no significant gender interactions in the effect of child social support child strain and relationship equity on parents psychological distress both in the baseline and in change over time results displayed in model 1 of table 3 and figure 3 indicated that controlling for the level of dissatisfaction fathers experienced less psychological distress than mothers in the baseline among those with higher baseline levels of dissatisfaction fathers experienced a less rapid decline in psychological distress over time than mothers these findings are mostly inconsistent with hypothesis 4 in addition we examined whether the parentchild relationship varied by age and race but did not find significant interaction results discussion relationships with children are central to aging parents wellbeing across the life course yet previous research has focused on the consequences of having minor children on parents wellbeing failing to determine whether relationships with adult child shape change in psychological distress over time articulating whether the parentchild relationship at a single point in time predicts change in psychological distress over time is critical in these earlier experience may set a trajectory of worseor betterpsychological distress as ways that accumulate over time into advancing age this is especially important for aging populations who experience the accumulation of psychological distress over time and thus may be at higher risk of worse health later in life this study uses longitudinal populationbased analysis to move beyond the early years of parenthood testing how multiple dimensions of adult childparent relationships are protective of or detrimental to parents psychological distress in midto later life we find that while social support and strain have a limited effect on parental wellbeing over time dissatisfaction and equity play an important role in parents psychological distress over time and the effects of dissatisfaction differed for mothers and fathers we outline three main contributions of the study subsequently first higher baseline support from adult children was negatively associated with baseline psychological distress while higher baseline strain was positively associated with baseline psychological distress the effects of social support and strain mattered for parents psychological distress in the immediate but were not long lasting the consequences of support and strain in the parentchild tie may dissipate over time wherein support becomes less effective and strain becomes less harmful for parents wellbeing for example parents may learn to cope with and become resilient to strain with children in ways protective of psychological distress while social support from children may not have a sustained effect on parents wellbeing support from children may also be a doubleedged sword as it implies the need for support this finding has potential implications for the way scholars view social support and strain from adult children on aging adults wellbeing as these components of the parentchild tie may be less salient to psychological wellbeing than previously theorized additionally itmay be that parents psychological distress is driving adultchild parent social support and strain a reverse causal effect we cannot tease out at the baseline level second parental dissatisfaction and equity of exchange mattered for parents psychological distress at the baseline and over time when baseline levels of dissatisfaction were high parents experienced higher levels of psychological distress at baseline over the course of the study period following a lifecourse perspective dissatisfactionwhich included being unhappy with the way a child turned out and unhappy with a parenthood rolehas lasting consequences for parents wellbeing parenthood is a salient social role and unhappiness with that role may present parents with chronic dissatisfaction that infiltrates ones sense of selfefficacy success and notions of selfworth which may in turn influence psychological distress similarly being dissatisfied with how a child turned out is likely correlated with a childs stressful life circumstances such as unemployment health problems or intimate relationship problems thus trouble in adult childrens lives is linked to parents wellbeing via intergenerational stress proliferation in addition a childs stressful life events may contribute to a parents feeling that he or she failed at parenthoodlowering levels of life satisfaction mastery and selfesteem which in turn may increase parents psychological distress such dissatisfaction with a child may not dissipate in the short term but may become part and parcel of a parents sense of self and identity affecting longterm wellbeing as figure 1 suggests further when parents and children exchanged equal amounts of social support or when parents offered more help to adult children at baseline parents had lower levels of psychological distress both at baseline and over time than those who received more help from adult children it may be better to give than to receive or at least it is better to give equally this may be especially true in midto later life when receiving social support may be strongly linked to requiring more help from adult children than at previous life stages receiving help may reflect the fact that parents are perhaps unable to care for themselves which is in turn associated with an increase in psychological distress over time however we included a control for functional health limitations and this did not change this significant finding suggesting that a parents functional health is not underlying this effect giving equal or more social support may boost selfsalience provide a sense of purpose and lower stress levels which in turn may lower psychological distress both initially and over time third nearly all findings operated similarly for mothers and fathers with the exception of parental dissatisfaction and among those with higher levels of baseline dissatisfaction mothers had higher rates of psychological distress at baseline than fathers compared to fathers mothers both in our sample and in most previous research received significantly more social support from adult child had lower overall levels of dissatisfaction with children and had more contact with children than fathers it may be that mothers invest more deeply in their children and therefore satisfaction or dissatisfaction in the parent role has more salience and consequences for mothers relative to fathers fathers who have high dissatisfaction may experience qualitatively different perhaps less invested relationships with their children and therefore are not affected by this high level of dissatisfaction this may be a consequence of the structure of fatherhood and motherhood wherein fathers are less attached to children than mothers later in life and thus their dissatisfaction has little role in their own wellbeing limitations and conclusion limitations should be considered first we did not have a measure of instrumental support or financial support we did not also have a measure of direct ambivalence we were able to test indirect ambivalence but did not find that indirect ambivalence was a significant predictor of psychological distress gilligan suitor feld and pillemer have shown that the indirect measure of ambivalence is in fact primarily capturing the effects of intergenerational strain and thus our study is clearly limited in its ability to test the effects of ambivalence future research should test the effects of both direct and indirect ambivalence second our longitudinal data provided us the ability to look temporally at change in psychological distress over time yet reverse causality may play a role in our findings third due to the construction of the survey we were unable to ascertain the gender of the child and our measures of the parentchild tie were global assessments of all children significant work suggests that parents experience each child in their family differently thus future work should explore the relationship between individual children and parents psychological distress fourth although psychological distress tends to typically decline in midto later life some studies also reported evidence of a ushaped curve which may influence modeling of our growth curve trajectories and mask the relationship between adult childparent tie and parents psychological distress finally analyses not shown test change in social support strain equity and dissatisfaction variables between waves 1 and 2 but we did not find significant and robust findings however we were only able to test change in a short period of time future research should explore how change across a longer time frame matters for parents psychological distress despite limitations our findings build on a growing literature on intergenerational relationships and health by detailing the specific aspects of the parentchild tie that appear to matter for parents longterm psychological distress we find that dissatisfaction and equity not social support or strain have the strongest effects on parental distress over time while intergenerational solidarity and conflict are viewed as the main sources of stress and strain among parents these factors seem to matter less over time for parents wellbeing thus measures of dissatisfaction and equity are independent predictors and should be the site of future research on the intergenerational tie and health this study suggests a more nuanced approach to the effects of parentchild relationships may lie not in dimensions of support and strain but rather more specific predictors of the parentchild tie across the life course biographies corinne reczek is an assistant professor of sociology and womens gender and sexuality studies at the ohio state university zhe zhang is a phd candidate in the department of sociology at the ohio state university predicted psychological distress by respondents level of dissatisfaction with adult children note the order of the lines from top to bottom respondent with high dissatisfaction and respondent with low dissatisfaction the value of high dissatisfaction is set at 055 and the value of low dissatisfaction is set at 097 predicted psychological distress by respondents relationship equity with adult children note the order of the lines from top to bottom children provides more support respondent provides more support and equal relationship predicted psychological distress by respondents gender and level of dissatisfaction with adult children note the order of the lines from top to bottom mother with high dissatisfaction father with high dissatisfaction mother with low dissatisfaction and father with low dissatisfaction the value of high dissatisfaction is set at 055 and the value of low dissatisfaction is set at 097

relationships with children are important for parents psychological wellbeing yet limited research addresses whether and how relationships with adult children matter for aging parents psychological wellbeing in midto later life we used four waves of national longitudinal data americans changing lives n 1692 and growth curve models to test how multiple dimensions of the intergenerational relationshipsocial support strain equity and dissatisfaction shape midto later life parents psychological distress over time results showed that social support and strain were associated with parents distress at baseline but not over time while relationship equity and dissatisfaction affected change in parents psychological distress over time findings further showed how the effects of dissatisfaction varied for mothers and fathers this study adds to an understanding of the social context of aging by drawing attention to how specific dimensions of the parentchild tie matter longitudinally for midto later life parents psychological distress

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background loneliness in older adults is a public health issue nowadays and deserves an increasing concern due to its negative effects in older adult population loneliness imposes a variety of health risks to older adults such as cardiovascular health risk declined cognitive function 1 increased morbidity and mortality 2 3 4 and poor mental health including depression anxiety and sleeping disorder 56 and health care utilization 7 loneliness is a unique clinical entity that deserves special and separate attention compared to other mental health issues such as depression and anxiety 8 the current study aims to examine the correlates of loneliness in the context of china with an ultimate goal of improving the design and the intervention of alleviating loneliness among older adults despite a sizeable literature on loneliness in western societies much less is known about loneliness in older adults in china a country where family system and collectivism are greatly emphasized and one where dramatic socioand demographicchanges have taken place in the past 40 years 9 the culture and the family in which an individual develops is an important factor that affects their experience of loneliness 1011 for instance dykstra found that older adults in more familialistic countries tend to be more lonely than those in individualistic societies 12 yum argued that loneliness is more about personal romantic expectations in some individualistic cultures but is more related to social approval and social network in collective cultures 13 embedded in a collective culture older adults may experience a higher risk of loneliness due to great changes including increasing migration smaller households the weakening of traditional filial piety and a rising number of emptynest older adults moreover people may be reluctant to acknowledge loneliness due to the chinese cultural influence the worse scenario is the unidentified loneliness and the invisible loneliness without timely interventions leads to even undesirable consequences as seeking help for emotional problems is less socially acceptable than for physical problems 1415 the cultural difference and the characteristics of the aging population in china deserve special attention and research to provide a better understanding of the phenomenon of loneliness although the definitions of loneliness are inconsistent in the literature loneliness is usually defined as a subjective negative and distressing feeling due to the deficits in social contacts 16 17 18 19 20 due to the inconclusive definitions of loneliness different measures have been used to assess loneliness mainly including ucla loneliness scale 19 de jong gierveld loneliness scale 162122 and a single item measure 923 the different measures make it difficult to compare the prevalence of loneliness of older adults in different countries or regions despite this research suggests that there is an increase in the level of loneliness in older adults in china for instance yang and victor found that the prevalence of loneliness of older adults increased from 156 in 1992 to 296 in 2002 9 similarly luo et al found that there was a significant increase in the mean level of loneliness from 2002 to 2008 using a nationwide survey 23 given the consequence of loneliness and the increase in the prevalence of loneliness in older adults in china it is imperative to examine the loneliness level in older adults and the factors that are important to loneliness an overview of the current literature reveals that the correlates of loneliness in older adults include sociodemographics health conditions and psychosocial factors the sociodemographic features associated with loneliness include being very old 18 gender 18 living arrangement 924 and marital status 2425 regarding health factors results imply that older adults with poor health in general tend to experience a higher level of loneliness as poor health may hinder the maintenance of social contacts and limit their daily activities that could be used to cope with loneliness 26 measures that have been used included selfrated health 2527 chronic diseases and adl disabilities 27 28 29 in addition social factors were also found to be associated with loneliness including social contacts 3031 social relationship satisfaction and social participation 932 in addition to these wellstudied variables in the literature new media use in older adults has been a hot topic in the communication research most studies have examined the characteristics of older adults who use new media or not and the reasons why older adults do not use new media 3334 another line of research is about the impact of new media use on older adults wellbeing 3536 andquality of life 37 previous research suggests that the use of new media could be used to reduce loneliness in the older adults 38 for instance social media is a perfect platform for older adults and their family to communicate especially when older adults usually do not share the same household with their adult children nowadays nevertheless there is also research suggesting that the internet use doesnt necessarily benefit older adults in terms of loneliness 39 in china the ownership rate of smartphones in middleaged and older adults reached 956 40 and more specifically the internet penetration rate in shanghai reached 741 41 new media has greatly impacted older adults way of living such as reading news entertainment and social contact given the prevalence of new media in older adults how it will impact older adults loneliness needs more research despite a large number of literature on the correlates of loneliness to the best of our knowledge little is known about the agegroup differences in the correlates of loneliness of older adults gerontological research suggests that the older adult population is not homogeneous and there are two phases in late adulthood that are characterized by various qualitiesnamely the young old and the old old 42 43 44 the young old who are in their postemployment stage are generally well functioning both physically and cognitively and are actively socially engaged 42 43 44 however the old old often face increasing limitations to their independence due to more chronic conditions and health restrictions and have a lessdesirable psychological profile and more deathrelated 42 43 44 the different internal and external conditions associated with the two age groups may play a significant and differential role when older adults adapt to the agerelated changes such as social losses or loneliness previous research on correlates of wellbeing and life attitudes actually indicates an agedifferential pattern for instance isaacowitz and smith found that cognition and social relationships were significant predictors of positive affect only for the young old but not for the old old 45 similarly jopp et al supported agedifferential correlates of valuation of life such that health factors was especially stronger for the young old than for the old old 46 these findings demonstrated that the correlates of loneliness might operate differently for the young old and the old old for instance the young old who are relatively healthier may compensate for being lonely by socially engaging in different activities such as volunteering or square dancing however this might not be the case for the less healthier old old further empirical research is necessary to provide a more comprehensive picture of the extent to which the importance of the correlates of loneliness would vary in the two stages of later life we focused on older adults in shanghai in the current study china represents the largest aging population around the world the population aged 60 and above accounts for 167 of the total population by 2016 47 among the cities shanghai is the first aging city of china and has been an aging city since 1979 and the percentage of its aging population has reached 332 by the end of 2017 48 which is almost twice higher than that of the whole nation in addition to the high percentage of older adults the aging population in shanghai is also characterized by a high percentage of the oldest old and those living in empty nest households the percentage of the oldest old has reached 164 among the older adults the number of older adults living in empty nest households is more than 1 million among of whom 03 million are 80 years old and above in this sense shanghai becomes an ideal place to examine older adults loneliness and its correlates we believe such a study in shanghai would shed light on the loneliness in other cities in china and would provide statistics to compare with other countries the present study this study aims to examine the correlates of loneliness in older adults in shanghai china and to explore whether there are age group differences in the correlates of loneliness this study intends to address two gaps in the literature first the loneliness of older adults in china is relatively neglected research on this populations loneliness would enrich our understanding of such a phenomenon second the older adult population varies in terms of health and social characteristics thus it is meaningful to identify the important correlates for the young old and the old old and this would provide evidence on tailoring agespecific prevention and intervention programs method data we used the shanghai urban neighborhood survey which started in 2015 and was completed in 2017 by center for data and urban sciences the data was sponsored by iii project of sociology shanghai gaofenggaoyuan project the data used probabilityproportiontosize sampling method with implicit stratification in particular the survey was conducted through three stages the primary sampling unit was administrative subdistrictstowns the second sampling unit was administrative villagesneighborhood communities and the third sampling unit was households communitylevel survey was conducted in a randomly selected 537 communities among 5732 in the whole city household survey was conducted in a representative 180 communities and all the individuals in the household sampled responded to the survey suns is the largest citywide survey that covers a variety of multilevel information including sociodemographics healthrelated information attitudes towards family and community social governance and community information 41 inclusion criteria included participants were willing to respond the survey there were no language barriers participants have sufficient cognitive capacity to communicate a sample of n 8631 adults was interviewed as our study focused on loneliness in older adults only older adults aged 60 or above were included in the current analysis please see research 49 50 51 for the details of the methodology measures loneliness we used the de jong gierveld sixitem scale for loneliness 16 to measure the overall loneliness the scale has been translated into chinese and proved to be valid and reliable measure of loneliness in chinese older adults 2122 example item included i experience a general sense of emptiness and i miss having people around each item is measured on a 7point likert scale ranging from 1 completely disagree to 7 completely agree three items were firstly reversely coded and then the sum score of the 6 items was obtained ranging from 6 to 42 with higher scores denoting higher level of loneliness the reliability of the scale in this study was cronbachs α 060 sociodemographic variables the sociodemographic variables included age gender marital status education living arrangement and these variables has been found to be related to loneliness in previous research 52 health factors health variables included selfrated health the number of chronic illnesses and instrumental activities of daily living srh was measured by in general how would you rate your health and it was measured on 5point likert scale ranging from 1 poor to 5 very good we used the number of the chronic illnesses to indicate their objective health status with higher scores denoting more chronic illnesses in addition we used the iadl 53 to indicate older adults physical functioning and the scale consisted of 7 items eg food preparation shopping and transportation the mean score of these items were used to indicate the level of disability with higher scores denoting higher level of disability the reliability of the scale in this study was cronbachs α 090 social factors we included family functioning contact with neighbors volunteering playing mahjong and square dancing we used the 12item general functioning scale of the mcmaster family assessment device 54 to measure the overall emotional health and functioning of the family example items included we confide in each other and there are lots of bad feelings in our family 54 each item was measured on a 4point likert scale ranging from 1 strongly agree to 4 strongly disagree epstein et al reported that the fad general functioning scale had high reliability as well as good concurrent and predictive validity 54 six items were firstly reversely coded and then the mean score of the 12 items was obtained with higher score denoting better family functioning the reliability of the scale in this study was cronbachs α 074 we asked participants to report the frequency of visiting or chatting with neighbors in the same community based on an option ranging from 1 almost every day to 9 almost never and this item was reversely coded with higher scores denoting higher frequency participants also reported whether they volunteered in the previous year with an option of yes and no in addition participants reported the frequency of playing mahjong and square dancing based on a 9point likert scale ranging from 1 almost every day to 9 never we reversely coded these two questions so that higher score denoted higher frequency of playing mahjong and square dancing new media use we asked participants to answer four new media use questions we asked them how often do you … online including read news search healthrelated information use qq wechat or other social media website and entertain like playing games watching videos and listening to music the questions were measured on a 5point likert scale ranging from 1 never to 5 almost every day the average of the questions was used to indicate the frequency of new media use with higher scores denoting more frequent new media use the reliability of the scale in this study was cronbachs α 090 method of analysis for variables with less than 2 missing values we replaced missing values with the mode of those variables for variables with more than 2 missing values we used the multiple imputation to replace the missing values we presented the descriptive statistics and compared the differences of the variables in the young old and in the old old using ttests and chisquare tests regression was then used to examine the correlates of loneliness in the whole sample first four models were designed we included sociodemographic variables in model 1 model 2 added healthrelated variables model 3 added social factors and model 4 added new media use in addition we also examined how the correlates would vary across in the young old and in the old old the classifications of the two age groups vary in the literature and we divide the aging population into two groups of 6079 and 80 based on the approach that has been widely used in previous studies in china 5556 we tested the collinearity issues and vif showed that there was no such issue 57 results the mean age of the participants in this study was 6972 years old the majority of participants were current married with a highest education of junior high or lower and living with others in addition 112 volunteered in the previous year we also compared the differences of the key variables in the young old and in the old old moreover there were significant agegroup differences with respect to marital status education living arrangement volunteering experience objective health indicators contact with neighbors playing mahjong and new media use compared to the young old the old old had a higher percentage of being widowed were generally less educated and were more likely to live with others about 13 of the young old reported volunteering but only 23 of the old old did in addition the old old reported more iadl and chronic diseases and lower level of chatting with neighbors square dancing and new media use compared to the young old in terms of loneliness the mean score was 1848 the loneliness level in the old old was significantly higher than that in the young old regression results in the whole sample as table 2 shows in model 1 age hukou marital status education and living arrangement were significant compared to married older adults those who were single and divorced experienced a higher level of loneliness whereas the widowed older adults were not significantly different from their married counterparts in terms of education those with an education of high school and higher reported a lower level of loneliness compared to their less educated counterparts older adults living alone reported a higher level of loneliness than those living with others in model 2 srh iadl and chronic diseases were significantly correlated with loneliness such that better health status was correlated with a lower level of loneliness in model 3 family functioning chatting with neighbors volunteering and square dancing were negatively correlated with loneliness satisfactory family relationship as well as higher frequency of contact with neighbors volunteering and dancing were correlated with a lower level of loneliness in model 4 more frequent new media use was related to a lower level of loneliness regression results by age groups we further run the regression in the young old and in the old old results revealed that there were agegroup differences in the correlates most of the significant correlates observed in the young old were identical to the findings reported for the total sample with an exception for living arrangement living arrangement was found to be significant only for the old old in addition variables that were significant for the young old lost their significant effect for the old old including hukou marital status education iadl contact with neighbors social participation and new media use however srh and family functioning remained significant for the old old discussion the present study represents a first attempt to investigate loneliness in older adults of shanghai china with a particular attention on the similarities and differences in the correlates between the young old and the old old in the backdrop of emerging sociodemographic features we found that the old old reported a higher level of loneliness and health status and social factors were important correlates of loneliness in addition analyses revealed an agedifferential pattern such that srh and family functioning were important for both the young old and the old old whereas marital status education social participation and new media use were significant only for the young old we found that 4 to 39 of the participants agreed with at least one of the six items of the de jong gierveld loneliness scale which suggests that the level of loneliness is not very high as expected but still a small proportion of the sample acknowledge the feelings of loneliness this finding challenges the oftenheld notion that older adults are lonely there are several possible reasons first older adults may be reluctant to acknowledge the feeling of being lonely as direct admission possibly indicates a lack of a satisfactory family relationship and in turn compromise their selfworth second some older adults who live alone may have the necessary resources to choose such a living arrangement to pursue a sense of autonomy 5859 especially for the young old living alone is not a significant risk factor of loneliness and this finding implied that living alone may not necessarily cause loneliness instead it might be a personal choice out of autonomy and an indication of independence more research is needed to explore the reasons behind such a phenomenon more importantly we noticed that those who were older with rural hukou single and widowed less educated living alone in poorer health with poorer family functioning less socially engaged and less frequent in using new media tend to experience a higher level of loneliness and this suggests a disadvantage accumulation phenomenon it is imperative to understand the meaning reasons and level of suffering implied on those feelings of loneliness and to design multifactorial interventions that target the deficits for older adults at high risk of loneliness consistent with previous research the mean level of loneliness was higher in the old old than in the young old 1218 the old old experience more physical limitations and more social losses and their expectations for social contacts may be difficult to fulfill thus they experience higher loneliness than their young old counterparts regarding gender differences we did not find significant results this is in line with previous research implying that gender alone may not be directly related to loneliness but rather interacts with other factors such as marital status and living arrangement 18 in addition compared to married older adults those who were single and divorced reported a significantly higher level of loneliness whereas the widowed older adults were not significantly different from their married counterparts most of older adults support needs are satisfied by their spouses being single or divorced implies an absence of such an intimate relationship thus leading to more loneliness 60 however widowhood might be more of a normative state than being single or divorced for older adults 61 and this state imposes a less impact on loneliness especially when they have a satisfactory family relationship moreover more educated older adults tend to experience less loneliness because they generally have better coping abilities and more resources to enrich their life and combat loneliness 62 compared to other living arrangements those living alone reported a higher level of loneliness and this is consistent with previous findings 63 in terms of health factors the three health indicators in the study were all significant such that better health is associated with a lower level of loneliness the loss of social contacts is part of the aging process and poorer health further imposes obstacles for older adults to socialize to effectively communicate with others and to participate in social activities all of which could be used to cope with loneliness 2664 less healthy older adults may also possess less resilience and lower selfefficacy to establish and maintain social contacts thus older adults in poorer health are at higher risk of loneliness in terms of social factors humans are social creatures and a higher level of social integration and connections are protective factors of loneliness helping those in need and maintaining engagement with others is two important feature of volunteering and it is a powerful antidote to loneliness because it gives people the opportunities to be needed 65 in shanghai there are about 26 million registered volunteers among whom 34 are over 60 years old by 2016 66 and being a volunteer serves as a meaningful buffer for older adults loneliness in addition as there is an increase in the number of emptynest older adults neighbors are more easily available due to the proximity and would be especially important for older adults daily contacts thus associating with a lower level of loneliness 18 an important question we examined in the current study is the agegroup differences in the correlates of loneliness results revealed that srh and family functioning are two very important correlates for both the young old and the old old srh is a global measure of health status 67 and has been found to predict a variety of outcomes eg mental health mortality 68 and loneliness 69 even though srh is influenced by objective health there is evidence suggesting that the correspondence between chronic diseases and srh generally declines with age 70 the old old could still have a positive srh despite their poor health and this opens up the opportunities for the intervention to improve older adults srh 71 in addition family functioning is a very strong protector of loneliness in the context of china where the culture greatly emphasized family system individuals experience more intimate connections from family members have more emotional communication have higher mutual trust and are better able to adapt to changes or hardships in a wellfunctioning family all of which could minimize loneliness 3 it is interesting that some of the significant factors for the young old lost their significance for the old old variables including marital status education iadl contact with neighbors volunteering and square dancing were no longer significant for the old old these differences might be largely due to the differing qualities in these two age groups the demographic variables are no longer significant for the old old perhaps loneliness in the old old is more of a result of internal factors such as how they view their health and family relationship 46 the worse health status might be more of a normative phenomenon for the old old whereas worse health status is an offtime event for the young old thus leading to a significant effect of iadl and chronic illnesses only for the young old 72 healthier young old might benefit more from the social participation whereas poorer health attenuates the beneficial effect of social engagement for the old old it is also possible that the level of social participation in the old old does not reach the minimal level beyond which social participation can be effective for alleviating loneliness more importantly new media use was associated with lower loneliness for the young old but not for the old old perhaps the young old who are relatively healthier are more affected by the pervasive new media and are more capable of using the new media to communicate with others to read what they are interested in to entertain on the new media than the old old 3334 this study has meaningful implications for interventions of alleviating loneliness first our study challenges the negative stereotype that older adults are lonely actually the majority of the older adults reported being not lonely nevertheless those who reported being lonely and those with higher risk of loneliness deserve more concern second agegroup differences were found for the correlates of loneliness and agetailored interventions are needed to better help older adults prevent or combat loneliness for instance interventions addressing srh and family functioning are appreciated for both age groups and those creating more opportunities for the young old to volunteer also could be helpful third in an era of new technology we could take advantage of new media to help them enrich their life and better communicate with their family or friends such as teaching older adults how to use new media to chat with family or friends study suggested that contemporary information and communication technologies have the potential to prevent or reduce the social isolation of older adults 73 lastly future interventions would be beneficial using a lifecourse perspective targeting risk factors at earlier stages of life could also prevent loneliness at later life stages there are several limitations that should be noted first the study is based on a crosssectional dataset thus the causal relationship among the variables cannot be established in the study future research is needed to examine what factors predict the onset and the alleviation of loneliness using longitudinal data thus providing more robust evidence for interventions second other factors that could possibly influence loneliness are not considered given the current information of the data such as personality and communitylevel factors it would benefit if future research could incorporate multilevel factors to provide an overarching picture of loneliness of older adults third participants included in the study were only communitydwelling older adults the results may not be generalized to those who live in the institutions conclusions our study examined correlates of loneliness and as far as we know and was the first attempt to explore agegroup differences in loneliness of older adults in shanghai china where population aging displays its unique features results revealed that loneliness in older adults does not prevail as the negative aging stereotype suggests older adults who are living alone single and divorced less educated in poorer health less socially engaged less satisfied with family relationship and less frequent in using new media are at a higher risk for loneliness in addition different important correlates of loneliness in the young old and in the old old are identified such that some essential factors in the young old lost their significance in the old old future interventions should be tailored to the young old and the old old to better help older adults alleviate the loneliness and enhance their wellbeing abbreviations iadl instrumental activities of daily living srh selfrated health authors contributions fy designed the study and drafted and revised the text jz and jw revised the text fy and jz performed the analysis jw supervised the analysis all the authors read and approved the final version of the manuscript competing interests the authors declare that they have no conflicts of interest

background loneliness is a public health concern with serious health consequences in older adults despite a large body of research on the correlates of loneliness little is known about the age group differences in the correlates given that the older adult population is heterogeneous this study aims to examine the correlates of loneliness in older adults in shanghai and to explore how the correlates vary across different age groups methods we used the shanghai urban neighborhood survey suns which was conducted in 2016 and 2017 the total sample size of older adults included in the analysis was 2770 loneliness was measured using the sum of the 6 items derived from the de jong gierveld loneliness scale correlates include demographic variables health conditions social factors and new media use regression analysis was used to examine the correlates of loneliness first in the whole sample and then in the young old 6079 years old and the old old 80 years old separately results the mean of loneliness score was 1848 sd 577 the old old reported a higher level of loneliness than the young old variables including age living arrangement marital status education health family functioning volunteering square dancing and new media use were found to be significant in the whole sample most of the significant correlates observed in the young old were identical to the findings reported for the total sample with an exception for living arrangement selfrated health srh and family functioning were two important correlates for the old old conclusions correlates of loneliness vary for the young old and the old old the older adults at higher risk of loneliness deserve more attention and concern future interventions should be tailored to the young old and the old old to better help older adults alleviate loneliness and enhance their wellbeing

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introduction there are numerous factors for people seeking health care such as limited activity number of chronic diseases severity of symptoms and selfreported health status 1 these reasons are much more common among the elderly especially in those suffering from dementia 2 dementia is characterized by deficits in more than one cognitive domain affecting language praxis gnosis memory or executive functions 34 memory must be affected although it may remain relatively preserved in initial stages of some forms of dementia 5 also the condition must be sufficiently severe to interfere in the patients daily activities 45 epidemiological studies have demonstrated that dementia incidence and prevalence has increased exponentially with the advance of age 4 despite scarcity of epidemiological surveys in brazil it is known that progressive population aging imposes great burden to society 6 this economic psychological and social burden is set to increase considering estimates that 25 of brazilians will be elderly by 2050 6 in developed countries dementia prevalence doubles every 5 years 7 among the different causes of dementia the four most common diseases are alzheimers disease vascular dementia frontotemporal dementia and lewys bodies dementia 56 ad figures as the most frequent form of dementia representing 50 to 80 of all cases 6 ftd is responsible for 5 to 10 of dementia cases 6 there is also parkinsons disease with dementia 8 another significant cause of dementia sharing several features with ld complicating their specific diagnoses 9 plus mixed dementia which exhibits clinical and pathophysiological findings of both ad and vd concomitantly 10 despite the essential economic growth observed in many developing countries especially over the last century huge differences remain in health care whether among nations themselves or across different regions of the same country this can be explained in most cases by unequal economic development insufficient distribution of financial resources inefficiency of public health care programs or because of differences between the health care services utilized 11 in brazil since 1989 public healthcare has been based on the sistema único de saúde sus which grants free health care at all levels of complexity to all citizens respecting their individual needs aiming to prioritize the most critical cases 12 the system is financed by taxes and social contributions but private initiative also plays a part in the process by providing physical infrastructure and human resources numerous clinics hospitals and laboratories as well as many health professionals engage in activities for public and private services concomitantly 13 the sus has financing and management issues in several regions of the country this creates significant disparities between public and private healthcare systems especially with regard to patient accommodation health care and resource availability and individual followup 14 in view of the scenario outlined the aim of this study was to assess the management and main features of dementia comparing public and private referral services in the city of ponta grossa southern brazil methods a retrospective analysis of the medical records of all patients admitted by the sus in the neurology outpatient unit of the university teaching hospital of campos gerais and also of all patients treated at the neurology service of the private clinic inovare serviços de saúde ltda spanning from the beginning of 2011 to the end of 2013 both services were located in the city of ponta grossa state of paraná southern region of brazil attending neurologists were the same applying the assessment and treatment criteria for dementia determined by the american academy of neurology and the brazilian academy of neurology 1516 this study was approved by the research ethics committee of the state university of ponta grossa brazil selection criteria medical records with the following characteristics were included 1 presence of sufficient data to characterize the ds and to determine its specific etiological entity and 2 patients followed by a physician working at both the services evaluated data collection clinical records were systematically assessed demographic and sociocultural data were collected age gender ethnicity schooling occupation residence smoking and alcohol abuse along with clinical data time elapsed since the onset of symptoms and admission in the neurology service score on the minimental state examination 17 at admission family history of dementia comorbidities brain imaging tests required and the type of therapeutic approach for dementia treatment after data collection patients with dementia were classified into specific diagnoses according to established diagnostic criteria the dsmiv criteria 3 were used to confirm the diagnosis of ad vd and md for confirmation of pdd the diagnostic criteria for mild cognitive impairment in parkinsons disease were used 18 for ld the criteria in the consensus for clinical and pathological diagnosis of dementia with lewys bodies were employed 19 and for the diagnosis of ftd the criteria of the consensus for clinical and pathological diagnosis of frontotemporal dementia were applied 20 for ad based on individual scores on the mmse 14 at admission patients were staged according to the severcamargo chf et al ity of the dementia scores below 10 defined advanced disease and above 19 to 26 defined mild disease 21 comparison between groups subjects fulfilling the selection criteria were divided into two groups the publ group based on the medical records of patients attended at the hurcg representing the public healthcare system and the priv group based on the medical records assessed at inovare representing the private healthcare system statistics all data were tested according to the distribution pattern statistical differences between group means were determined using the onetailed students ttest for normal distributions and the mannwhitney test for nonnormal distributions for the differences between the expected values and the values actually found the chisquare test with yates correction and fishers exact test were used the results were expressed as mean ± sd differences were considered significant for p 005 results thirtyfour patients for the publ group and 166 patients for the priv group were selected subjects treated in the private service had higher mean age and schooling and also lived more frequently in urban areas and had lower rates of smoking and alcohol abuse when compared to the patients that sought the public service the gender proportion differed significantly between group with 0481 in the publ group versus 1213 in the priv group for mean waiting period until admission and mean score on the mmse at admission a difference was observed between groups with regard to the specific diagnosis for dementia the patients under the public healthcare system took longer to be seen by the specialist waiting on average 208 years versus 124 years in the private service concerning investigation of the dementia there was significant difference regarding the standard brain imaging method for diagnostic support in the publ group 29 individuals underwent cranial computed tomography as the exam of choice while in the priv group only 66 had this test this pattern was inverted for head magnetic resonance imaging where 98 patients were submitted to the exam in the priv group versus only 8 patients in the publ group pharmacological management through acetylcholinesterase inhibitors was substantially higher in patients treated under the private system totaling 141 subjects compared with only 18 subjects in the public system it was observed that 9 individuals in the publ group used memantine versus only 12 in the priv group there was no statistically significant difference between groups for distribution of dementia into specific diagnoses except for vd which was more common among patients seeking the public healthcare system risk factors associated with vascular disease were similarly present in both groups except for smoking smoking was absent in the priv group while in publ group 4 patients were smokers for ad regarding severity of the disease when seen by the neurologist relevant statistical disparities between the groups were found in ad the priv group had 52 patients admitted in the service at mild stage of disease while in the publ group only 3 patients with this stage were admitted among subjects from the private system only 12 individuals had dementia at advanced stage upon seeking the service while in the public system 7 patients with advanced stage dementia were admitted the pharmacological therapeutic approach used in patients with ad showed significant differences between groups with mild dementia as depicted in table 5 discussion epidemiological and clinical data obtained through group analysis revealed substantial inequalities between those populations treated under the public and private services despite the fact that all patients were assisted by the same physicians with similar assessment and therapeutic protocols the mere finding that the number of subjects selected under the public system represents only about 15 of those under the private system could be an important indicator of the obstacles faced by patients with dementia gaining access to an attending neurologist in the public healthcare system this finding could also be related to a higher number of individuals from this area of the country seeking treatment in the public health system representing 2352 of the publ group likewise the lower average years of schooling in this population might have hindered the perception of the signs and symptoms of dementia perhaps explaining the delay in seeking medical care moreover considering the large socioeconomic difference observed in the population studied the involvement of cultural and socioeconomic features in the evolution of dementia could be implicated as a contributing factor to this difference another relevant issue is the disparity between the physical infrastructure of public and private services and its influence on the diagnostic and therapeutic management of dementia revealing the wide inequality in care between different regions of the same country 11 in countries where there is lower distribution of economic resources for healthcare the late diagnosis of dementia could be explained by several elements such as low schooling of the population concentration of diagnostic facilities in more remote large urban centers costs related to diagnostic management and the social stigma itself which accompanies dementia 22 it was observed that elderly patients with higher schooling and access to the private service received better health care corroborating the findings reported in india 2 and cuba 23 countries with a high percentage of people living below the poverty line in brazil besides major social inequality there are substantial differences in the quality of public healthcare assistance offered across the numerous regions of the country 2 in a study performed by dias et al 24 in brazils southeast region subjects assessed under the public system had lower waiting times before being seen and slightly higher mean mmse scores compared to the present study probably because of the better quality of health care services in this particular region another study by miranda et al 25 also performed in the southeast region involving a group of patients with features similar to those of the publ group showed an even shorter waiting time until diagnosis this difference is more evident when comparing to the reality of developed countries in a german study conducted by froelich et al 26 the research subjects had a mean mmse score of 197 points and mean waiting time until followup of 158 months reflecting the higher schooling and better accessibility to health care in the german population 24 on the other hand these findings for the german public healthcare system resembled the results found in the brazilian private healthcare system demonstrating the differences between this two countries health systems and how much needs to be improved regarding public health care in brazil to attain the quality and availability of developed countries the mean age of the priv group was significantly higher may be explained by elements such as lower incidence of risk factors among these individuals 27 higher prevalence of subjects at the mild stage of ad 28 higher schooling 27 greater concentration in the urban area 18 and access to the private assistance setting 2 in spite of the disparities between gender proportions both groups presented female predominance thus confirming this gender as the most frequently affected by dementia 429 however this differs from the reality found in some developing countries where male gender predominates among patients with dementia 23 in terms of specific dementia causes in the publ group the distribution followed the most common epidemiological pattern found in the literature showing ad as the main cause of sd followed by vd 629 however the priv group exhibited a different pattern with md as the secondmost prevalent similar to results found in other studies 1023 rockwood et al 10 in canada analyzed a sample of 603 patients with dementia 372 of whom had ad as the etiological diagnosis 76 md 73 vd and 82 with other types of dementia in a study performed in havana by libre et al 23 among 1499 patients with suspected dementia 464 had ad as the underlying disease followed by md responsible for 282 of the cases regarding the standard diagnostic approach for ordering brain imaging exams a notable difference was observed between the systems hmri despite being recommended as the method of choice for diagnostic brain imaging in dementia assessment 30 was significantly less available for diagnostic complementation in patients from the publ group nevertheless the vast majority of subjects treated under the public system had access to the cct scan an acceptable method to complement diagnosis and the therapeutic approach when hmri is unavailable 30 with respect to the therapeutic approach the use of acetylcholinesterase inhibitors drugs indicated for the treatment of all stages of ad dementia 26 and available free of charge under the sus differed substantially between the groups these drugs were more frequently used in patients from the priv group memantine a medication predominantly indicated for severe stages of dementia 26 and unavailable under the sus was significantly more used among patients from the publ group indicating the higher number of individuals with advanced cases in this group in a south african study published by truter 31 it was found that among prescriptions for the treatment of ad 2470 of patients received memantine as a standard pharmacological intervention this number was similar to the findings of the publ group suggesting a more severe clinical profile of patients treated in these services with probable late diagnosis of ad independently of dementia type disease stage or complementary method by which the diagnosis was obtained patients from both groups had good conditions of drug administration and continuous followup except for the individuals with mild ad under treatment in the public healthcare system all patients irrespective of group or disease stage had therapeutic coverage of over 60 in the use of acetylcholinesterase inhibitors in a french study performed by cantegreilkallen et al 32 631 questionnaires answered by general physicians about their patients with ad were analyzed it was observed that only 50 of patients received prescriptions of acetylcholinesterase inhibitors therapeutic coverage with antidementia drugs is even lower in the majority of european countries probably because of cultural preference for seeing a general physician instead of a specialist for followup 33 in brazil as in other developing countries there are major shortcomings in the implementation of programs related to elderly welfare and the raising of adequate financial resources to fund high social impact initiatives for the population with dementia as well as in the effective training of professionals and caregivers for scientifically accurate and humanized care of this patient group 34 the social and financial impact related to the care of patients with dementia falls largely on patients families 34 favoring those who have access to private means of care therefore it can be concluded that patients with dementia seeking the public service in the region analyzed have lower access to health care entering the system at more severe stages of disease while also having poorer therapeutic coverage in the use of acetylcholinesterase inhibitors compared to patients admitted into the private healthcare system

dementia is characterized by deficits in more than one cognitive domain affecting language praxis gnosis memory or executive functions despite the essential economic growth observed in many developing countries especially over the last century huge differences remain in health care whether among nations themselves or across different regions of the same country objective the aim of this study was to assess the management and main features of dementia comparing public publ and private priv reference services methods we performed a retrospective analysis of medical records of subjects with dementia sociocultural data mean followup time in the service minimental state examination mmse scores at admission main diagnosis of dementia family history of dementia comorbidities imaging methods and treatment were assessed results the time elapsed before admission in the service of the publ group 208±206 years was higher than for the priv group 124±255 years p00356 the mmse score at admission in the publ group 1505±816 years was lower than in the priv group 1895±669 years p0016 the publ group showed lower treatment coverage with cholinesterase inhibitors 5294 than the priv group 8493 p00001 conclusion patients seeking the public health service have less access to medical care reaching the system at more advanced stages of disease the public service also offered lower pharmacological coverage

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introduction the worldwide population is slowing down due to the spread of the current covid19 pandemic outbreaks of the new virus have spread to many nations worldwide on march 11 2020 the world health organization publicly named the illness the 20th of march virus as covid19 thousands of students have been affected by the covid19 pandemic spread across the globe and the lockdowns of their schools have further shocked their families and teachers thus restricting students access to learning especially in the absence of computers and internet facilities in many homes the covid19 pandemic is a public health emergency that has affected the education and other sectors of the economy which made policymakers to take two main decisions first to close down all learning and education centers and environments to reduce close contact with covid19 positive patients and second allowing workers in the manufacturing sector to continue operations in order to keep the economy active productively many schools and colleges were forced to close due to government efforts to contain the spread of the covid19 as there were no immediate solutions to stop the spread of covid19 at its early phase students ability to learn has been harmed due to the closure of several universities across countries for international higher education college students declined drastically worldwide the resultant effect is that learning centers eg colleges and universities adopt online learning platforms as alternative learning delivery mechanisms this is to ensure the continuity of institutions and universities activities universities rely on learning management systems and opensource digital learning solutions to offer online courses the old chalktalk model has been replaced by new technology however in online learning university students have been facing difficulties in understanding delivering and managing online lessons class assessments and laboratory experiments there is a lot of trial and error and uncertainty for everyone regarding student assessments moving online several tests have been canceled outrightly there are longterm consequences for the affected cohorts and an increase in inequality due to these interruptions the students would feel alone depressed indifferent or suicidal posing a psychological anxiety in their online learning process psychosocial anxiety means an uncomfortable and stressful feeling that a person experiences during a stressed or stressful situation many college students choose to study abroad international higher education is expected to decline due to the closure of institutions and universities worldwide related life experiences can affect multiple cultures but the perception of these events can affect individuals levels of suffering there are 14 billion undergraduate students worldwide pursuing higher education to curb the spread of covid19 education which is an important determinant of quality of life and a key to development was particularly affected after the who declared the outbreak a pandemic in march 2020 most countries worldwide closed all educational institutions to stop the pandemic from spreading further a report of unesco in 2020 estimates that school and learning space closures affect 94 of the worlds student population with the percentage rising to 99 percent in lowand lowermiddleincome countries according to the organisation for economic cooperation and development oecd higher education has been severely impacted by covid19 pandemic as many universities had been closed and countries also closed the boarders even though the higher education has been trying to replace face to face learning to online learning there has been many challenges faced by students who does not have adequate accessibility of internet and gadgets beside the learning facilities in this pandemic students also encounter the issues likewise personality social support which might impact on their daily life and particularly on academic performance other than psychosocial factors while teaching through online during this pandemic language fluency has been an issue for the students that can influence on the academic performance therefore stress is triggered by changes in students life coping capacity and potential life risk meanwhile students are often dealing with this due to the difficulty of living in a new environment and a clear desire to excel in life which causes more anxiety problems among the students therefore this study investigates the influence of chinese mobility and exchange students psychosocial factors on their academic performances during the covid19 pandemic this paper aims to contribute by adding the new inputs in body of knowledge besides it also can help the practitioners to get an insight on students psychosocial factors and its relation to academic performance the remaining paper follows with literature review and hypotheses formulation research framework research method results of the measurement and structural model and discussion followed by implications of the study and conclusion literature review and hypothesis development theoretical underpinning student involvement theory in current study we mainly examined the role of psychosocial factors on academic performance of the students during covid19 pandemic since the basis of this study comprised with students involvement in academic activities the research framework of the study underpinned by student involvement theory this theory initially developed by austin et al and modified in austin student involvement theory mainly emphasized on students involvement and development process in higher education previous studies also utilized this theory while explaining academic performance of students personality social support and language fluency therefore this theory considers most suitable while examining the role of psychosocial factors on academic performance of the students during covid19 pandemic psychosocial factors personality baumert et al explained personality as an individuals characteristic patterns of thought emotion and behavior together with the psychological mechanisms hidden or not behind those patterns personality traits are a persons ability to respond to a wide range of stimuli with the same level of thoughtfulness and determination regardless of the context in which they arise personality also can be described in terms of these two dimensions but two additional dimensions shed light on the concept of personality separate from those two individuals respond to vulnerabilities viewed as traits which triggered their personal behavior several studies have shown that research has been done on international students personality characteristics and psychosocial adjustment associations an individuals ability to cope with stress and manage their emotions is strongly influenced by their internal sense of control international students may affect the way they adjust psychologically due to the different personality traits of international students some multicultural or crosscultural student affairs experts should consider that most of the time due to stability its too difficult to change it research on personality is often done on an individual or small group basis without the primary framework in adjustment schermer et al stated that only a few studies are associated with personality factors in adjustment research international students have different adjustment experiences due to differences in personality management of change bulgan and çiftçi conducted a study in the united states with 243 participants to determine whether personality traits such as extraversion agreeableness conscientiousness and openness are linked to better psychological and sociocultural adjustment the study also found negative associations between neuroticism and better psychological and sociocultural adjustment and significant positive associations between these two variables extensive studies on students and adults have found positive associations between extraversion conscientiousness openness and their ability to adjust to their social environments social support social support is considered an important element that helps international students develop a basic sense of adaptation to the new social climate toker suggest that the decisive factor that plays a critical role in the current establishment abroad is social reinforcement allowing the dilemma of new growth and transition problems to be discussed in comparison social reinforcement plays a crucial role in stress control it helps control the framework and significant influences affecting interpersonal transition if somebody experiences ethnic or crosscultural challenges japanese scholars participation in extracurricular activities will serve as a buffering for a cultural shock for american students student participation also matters study showing that the number of students who are fully engaged in the other tasks and seen more easily adjusted in new culture and students with low segment experience the same adjustment problem they think that their anticipation and curiosity are distinguished from others to some degree ye et al examines those other activities usually minimize mental tension and help obtain environmental and social support there were seventyfour international scholars from korea in the pittsburgh area who concluded that the deep engagement is the explanation for obtaining high social support and because of the other behaviors that reduce their stress level as that student a significant contribution of american culture language and other personal relationships to obtain social support is the studys finding for instance the psychosocial transition is easier and more feasible as they obtain social support due to other external events and interesting resources for international scholars a study from united states of america concluded that international students from the same country will benefit from social help and some local students instruct them how to adapt to new ones the institution must also provide international scholars within the campus with the organizational culture and give them opportunities for partition to obtain social support that aids in adaptation in that situation besides universities should plan the style event that allows international students to engage with the host countrys community such as developing structured and nonformat activities student orientation and other services that enhance their social support level alsop and bencze focused on the markers of melancholy and nervousness in students worldwide and observed that social assistance had a vital commitment to the paradigm in expecting wretchedness specifically more elevated levels of depression were identified by students with lower levels of social support in addition to rejection they also discovered that social support tended to reduce nervousness especially for students with lower social support levels who were more likely to have greater levels of discomfort the imperative of using the social support structure to alleviate the detrimental impacts of cultural assimilation on mental prosperity has been demonstrated by late work foreign students were helped socially with psychological wellbeing which plays a major role in controlling their community to build a positive atmosphere for social help due to covid19 pandemic a significant number of students are facing a lack of happiness the efficiency of some of the better forms of social care that implicitly support international scholars as they suffer from psychological stress in prosperity several studies suggest that international academic tension should be minimized with academic and social assistance it may be possible to establish a network to provide cultural event facilitation and reduce stress relevant to the culture language fluency people who have a stronger connection with foreign nationals speak a more understandable language than those who do not language capacities are crucial for the social transition based on this premise insightful foundations should offer and assist students in developing their english language fluency according to scholars oweis english capacity and change are related researchers also examined how language capability in english affects student success in mumford and dikilitaş a group of researchers from turkey deliberated the affecting factor from social introspection progress in these areas depended on proficiency with the english language as the students english was higher than other figure 1 research framework students they were happier in britain it is correct that most international students were joining from various countries most are coming from malaysia and have language as an obstacle and a similar situation was faced by international students in malaysia at the university of malaya the study needs a lot of time to understand the instructions provided by the teacher thoroughly around the same time there are language assessment standards for international students from several different countries including toefl ielts and the highintermediate certificate of cambridge english most people define barriers from international scholars in terms of academic changes language and contact the inability of international students to communicate with natives is a common issue particularly in the test kruk believed that language anxiety had existed on the students simple change according to flesia et al their low degree of stress is attributable to their welleducated in english and global communication skills formally effective interactions play a critical role in academic adjustment to international according to these researchers participants assessment of fluency in english is affected by their englishspeaking capacity competency in the language is of much significance for foreign academics academic performance social neurological and environmental conditions impact higher education according to previous work students with the best academic records performed well in college high school grades were great predictors of college grades more recent attempts have objectively evaluated student achievement graduation and teaching standards as distinct academic metrics of academic progress as for student satisfaction the effectiveness of instructional approaches and learning qualities can be ascertained student satisfaction is the positive assessment scores of learners about the diverse consequences and expectations associated with schooling study happiness is not consistent with academic achievement a strong association was observed between students happiness and academic achievement happy students are also significantly more successful in contrast students satisfaction is influenced by noncognitive variables such as motivation and classroom communication rather than cognitive variables such as grades at the same time there is evidence that psychosocial traits in contrast personality and emotional intelligence can positively affect academic achievement and student progress and the results are also inconsistent based on the above literature this study has come out with the hypotheses and research framework please see research methods the study adopts the quantitative approach to achieve the objectives of the paper besides the study uses a questionnaire designed on a 7point likert scale to elicit data on the variables contained in the research framework a total of 200 questionnaires of the mobility psychosocial factorsacademic performance scale was administered to chinese outbound exchange and mobility students a total of 186 questionnaires were found usable for the study after accounting for sample bias using straight lining for responses having standard deviations between 0000 and 0500 table 1 below shows the references of the measurement items used for the constructs in this study measuring instrument the measuring instrument for the current study has two sections section a describes the demographic information of respondents the pace of delivery of the teaching is reasonable including gender marital status age current semester and programme of study section b consists of the items on the main variables in the formulated hypotheses of the study chinese exchange students rated their opinion for personality language fluency social support and academic performance during covid19 pandemic on a sevenpoint likert scale personality is measured using eight items adopted from eysenck and modified by tellegen and waller the items include i find it very easy to use train timetables even if this involves several connections five items were adopted from birman and trickett and takeuchi et al to measure language fluency of the students these items were previously used and validated by spada and lightbown the items include i like to know exactly which grammar point i am studying social support was measured by eight items adopted from scott et al and gregory et al the items include there is a special person who is around when i am in need academic performance was measured by nine items adopted from mercugliano et al these items were previously modified and validated by yousef the items include the way the lecturer speaks is important in understanding the lecture results and findings respondents information table 2 represents the respondents demographic distribution for gender marital status age and the number of semesters completed by students exchange and mobility out of 186 respondents 624 respondents are male and 376 are female the majority of the respondents are single 849 and married are 14 in terms of age group the highest age group consists of 2022 years old 441 followed by 1719 years old which is 231 2325 years old 156 29 years old and above is 102 and 2628 years old 72 students are currently in different semesters of their study many of them are from semester 1 to 2 which is 446 followed by semester 5 to 6 is 328 semester 7 to 8 is 177 and remaining is semester 3 to 4 48 for the program of the study majority of them are undergraduate students followed by masters 204 and phd is 7 measurement model assessment for the data analysis the researcher used smartpls version 30 following dijkstra and henseler a consistent algorithm was applied to evaluate the convergent and divergent validity of the variables used in the study all the items should load at least 060 composite reliability more than 070 and average variance extracted above 050 to confirm convergent validity as shown in table 3 and figure 2 the four variables used in this study are reliability and validity the reliability measure where any single variable meets the conditions is cronbach alpha it implies that all variables included in the analysis have passed the validity reliability arguments besides cr was above the recommended value while the extracted average variance was above 050 in table 4 the heterotraitmonotrait ratio is considered further to assess discriminant validity the smartpls assessed the latest method html ratio is shown in table 4 to confirm that all the variable meets certain conditions as their correlations do not exceed the value of 085 in table 5 variance inflation factors are used to assess any high collinearity among the constructs items based on the outer loadings the measurement model found only personality 1 to have more collinearity with one of the study items which is acceptable since no other items showed high collinearity structural model assessment we have used statistical method and bootstrapping suggested by zhao et al nitzl et al andrasoolimanesh et al to test indirect effects the study uses the bootstrapping method to assess the structural model to determine the direct effects of language fluency personality and social support on the academic performance of chinese outbound exchange and mobility students during the covid19 pandemic table 6 and figure 3 shown that language fluency personality and social support have significant influences on students academic performance however the relationship between social support and students academic performance is negatively significant goodness of fit concerning the model fitness of the constructs used in this study this study considers srmr values as the most important criteria although hair et al concluded that it is unnecessary to examine model fitness in smart pls using srmr values discussion due to the global pandemic since march 2020 students worldwide were feeling anxiety fear of academic failure and fear of academic year loss which can have a significant impact on the overall academic performances of the students consequently the covid19 pandemic has brought considerable changes in the overall academic environment making the students uncomfortable to cope with the new academic environment and badly impacting the students academic performance nevertheless the impact of the covid19 pandemic becomes more acute for the mobility and outbound exchange chinese students as they come only for a short period to complete either one or two academic semesters in other abroad universities hence this study examines how covid19 impacts the academic performance of the chinese outbound exchange and mobility students further this study examines the relationship between personality language fluency social support and academic performance of chinese outbound exchange and mobility students during the covid19 pandemic to achieve this objective the researcher has three main constructive hypotheses in this study first and foremost this study considers the students personality as one of the main factors that either positively or negatively can impact the students academic performances hence the very first hypothesis of this study is that personality has a significant influence on the academic performance of chinese outbound exchange and mobility students furthermore language fluency is another crucial variable that has been given attention in this study assuming that language fluency can significantly impact students academic performance hence the second hypothesis of this study articulates that language fluency has a significant influence on chinese outbound exchange and mobility students academic performance furthermore besides the personalities and language fluency of the chinese outbound exchange and mobility students social support is one of the main factors that highly influence overall academic performance therefore the third hypothesis of this study is that social support has a significant influence on chinese outbound exchange and mobility students academic performance during the covid19 period moreover to examine the basement of the above mentioned three hypotheses this study utilized the plssem based on the analysis through structural equation modeling and plssem all the three main hypotheses of this study were accepted based on the threshold provided by hair et al and patwary et al as far as the first hypothesis is concerned the thorough analysis of this study shows that students personality has a significant favorable influence on the academic performance of the chinese mobility students studying in abroad countries the findings of this study imply that students who possess strong personalities can deal with emotional psychological and physical problems efficiently during the pandemic time which help them to perform consistently better in their academic examinations further several previous studies also show that students personalities positively influence the students academic performance further the second hypothesis of this study confirms that those students who have higher language fluency tend to achieve more academic success regardless of the pandemic the finding of this study assures that students who have reasonable control over their language expertise can understand better the given task during the classes which help them to do the assignment and another class task properly moreover students with english language fluency can communicate better with their teachers and classmates which allow them to perform consistently better in the class tasks and during the exams previous studies conducted by oducado et al and thomas found similar results that language fluency increases students level of confidence which in return helps the students to achieve better academic performance lastly the third hypothesis results posit that the social support around students negatively affects the students academic performances during covid19 the chinese outbound exchange and mobility students have been suffering abroad due to the lack of proper social support since to tackle the pandemic situation most countries worldwide have implemented lockdown regulations that have prevented any types of physical social support hence students are also prohibited from any social gathering making the students feel more lonely isolated and helpless therefore due to the lack of social support students are emotionally weak and perform poorly in their academic results further the findings of the recent studies also supported the third hypothesis of this study which states that lack of social support around the students negatively affects the students academic performance thus the findings of this study show that students personality and language fluency positively influence the academic performances of the chinese outbound exchange and mobility students on the other hand lack of social support negatively impacts the overall academic performances of the chinese outbound mobility students during the period of covid19 theoretical implications first and foremost the core contribution of this empirical study focuses on the theoretical perspective in the research area of psychological factors affecting the performance of mobility students in previous studies most researchers have examined anxiety stress depression and emotion as psychological factors that affect students academic performances for instance hasan and bao have utilized the psychological distress model which can impact students academic performance further vargas et al have utilized noise temperature level and lighting as independent variables that can affect the academic performance of university students in addition eya et al have employed attitude motivation and selfregulation as sociopsychological factors that can impact the students academic performance further none of the previous empirical studies has implemented the above mentioned three psychological factors to explore the academic performance of the mobility students however in the context of this study the author has introduced new variables as psychological factors that can directly or indirectly impact the academic performance of mobility and outbound exchange chinese students moreover the three main psychological factors introduced in this empirical study are personality language fluency and social support furthermore this study has validated the eight items introduced by eysenck for the variable personality moreover this study also verified eight items for the variable social support developed by schieman also it validated five items for the factor language fluency which is taken from birman and trickett hence this study has added a new horizon in the perspective of psychological factors affecting the academic performance of mobility and outbound exchange chinese students practical and policy implications looking at the practical implication of this study this is one of the very first initiatives in the empirical study addressing the very recent covid19 pandemic phenomenon by introducing psychological factors such as personality language fluency and social support affecting the academic performances of the chinese mobility and outbound students usually mobility students go abroad for a very short period to study one or two semesters in another university to experience different cultures and environments moreover it is always challenging for mobility students to maintain excellent academic performance in a new environment nevertheless the recent covid19 pandemic has made it further difficult for mobility students to achieve better academic performance therefore this study would examine how psychological factors such as social support and personality affect the academic performance of the chinese mobility and outbound students during covid19 besides psychosocial factors language fluency is also a crucial factor for students that has significant influence on their academic performance therefore this study also examines the role of language fluency on their academic performance during covid19 pandemic further concerning the policy implication of this study the findings of this study would assist the administrators and executives responsible for maintaining the overall wellbeing of the chinese mobility and outbound students studying abroad moreover the responsible administrators taking care of chinese mobility and outbound students can use the findings of this empirical study to develop a new policy that can help the chinese mobility students enhance their academic performances furthermore the welcoming institutes and universities which invite the chinese mobility students can also utilize the findings of this empirical study to identify the psychological factors which affect the academic performances of the mobility students thus the valuable results of this study can help the administrators and institutions develop the rules and policies that can contribute toward achieving better academic performances for the chinese mobility students limitation and future study directions this empirical study has many significant contributions in the context of psychological factors impacting the academic performances of the chinese exchange and mobility students however this study has also a few limitations to be addressed in further studies firstly due to the current pandemic situation the data for this study was collected from purposively targeted two hundred sample students thus future studies can address an enormous population to achieve more diverse and accurate results secondly this study only focuses on the chinese exchange students which are a very narrow part of the group hence the findings of this study might only address the problems faced by the chinese exchange students therefore the future study can also include other countries exchange students to achieve the findings which will address the overall exchange and mobility students psychological factors affecting their academic performances lastly another limitation of this study is that this study applied a simplified model for conceptualizing the results consequently the future study can include more psychological factors as independent variables also it can include the moderating or mediating variables in the model to investigate the existed models from different aspects conclusion to sum up this empirical study inspects the impact of covid19 on the academic performance of the chinese mobility and exchange students from three main perspectives namely personality language and social support the findings of this study assure that chinese exchange students personality and language fluency has a significant positive relationship with academic performance however the lack of social support around the chinese exchange students due to the covid19 situation has a negative relationship with academic performance hence the findings of this study exhibit that psychological factors personality language fluency and social support have significant impacts on the overall academic performances of the chinese mobility and exchange students this study expects that the findings of this empirical study would help the chinese exchange students administrators and institutions have a better understanding of the psychological factors affecting students academic performances therefore based on the findings of this study the institution can take the necessary steps to help the chinese mobility and exchange students achieve better academic performances and maintain students overall wellbeing data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation 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

covid19 has affected every aspect of our life including economic social and academic exchange and mobility students face more difficulties overseas and chinese students are no exception however elearning has been introduced by institutions in many countries the present study examines the psychosocial factors affecting the academic performance of chinese outbound exchange and mobility students during the covid19 pandemic the study surveys about 186 chinese outbound exchange and mobility students the present study performs the quantitative data analysis using partial least square structural equation modeling plssem through the smart pls software version 3 by confirming the measurement model and structural model assessments the study finds that personality social support and language fluency are psychosocial factors that significantly influence the exchange and mobility students academic performance this study contributes by establishing relationships among psychosocial factors language fluency and academic performance besides practitioners can be benefitted by understanding students psychosocial factors and its relation to academic performance during covid19 pandemic

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the 2016 kaikōura earthquake experiences of safety evacuation and return for apartment dwellers in te whanganuiatara aotearoa new zealand over the past three decades aotearoa new zealand has undergone dramatic growth in innercity housing with an influx of people residing in apartment buildings these dwellings often multiunit structures are situated predominantly within innercity central business districts they require specific emergency management planning response and recovery strategies compared to suburban singlestory dwellings to this effect how hazards such as earthquakes matter to the lives of innercity residents must be understood this research was particularly focused on understanding how innercity residents experienced feeling safe and secure directly during and following an earthquake and how that may have influenced peoples actions extensive literature exists on evacuation for different perils including earthquakes tsunamis weather events floods volcanoes landslides fire chemical and nuclear events and for different timeframes including before during and after an event such literature recognizes that the nature of an evacuation differs depending on the context of the event and the timeframes available for evacuation in an earthquake context a short amount of early warning could prompt evacuation before ground shaking starts but this technology is not currently widespread in aotearoa new zealand and evacuation can only be undertaken during or after the earthquake to understand the ways in which feelings of safety and security intersect with innercity residents evacuation and return responses after an earthquake this study draws on the concept of ontological securitythe human need for a safe and secure existence the goal is to bolster knowledge about risk reduction and sustainability actions through understanding emotional drivers ontological security feelings of safety and security according to giddens ontological security or the experience of continuity that underpins much of human existence and experiences of trust and safety is a driver for action an emotional framework founded in the subconscious ontological security enables people to feel at ease therefore people consciously seek ontological security while ontological security can be conceptually ambiguous as argued by gustafsson and krickelchoi emotional processes or the embodiment of ontological insecurity can be interpreted through feelings of uncertainty anxiety and fear relatedly giddens posits that anxiety is distinct from fear in that anxiety is embedded within the wider system of security compared to fear which is often experienced in relation to a specific situational event such as an earthquake anxiety is a more generalized human emotion which is associated with a persons knowledge and experiences of agency in the world to sustain experiences of ontological insecurity people engage in routines and regularity of existence in its various forms where disasters are exogenous shocks to which people and systems must respond protecting ontological security can involve engaging in actions such as disaster preparedness and attempting to control environments however achieving ontological security is not always an equitable or dispassionate process hawkins and maurer and blake marlowe and johnston argue that people are constrained in their ability to prepare for a disaster because of a lack of social capital or resource inequity and are therefore subjected to greater ontological insecurity and increased risk of harm having a sense of ontological security or the need to exist in a world that is coherent and secure prevents people from taking action that might challenge these experiences for innercity apartment dwellers the agency to prepare for a disaster is compromised due to a lack of space to store survival items for renters agency is further compromised because of being potentially constrained in securing furniture and residing in unreinforced or earthquakeprone buildings coalescing with shaw padgett proposes that the physical aspect of having a dwelling alongside the subjective experience of having a home is implicated in the achievement of ontological security meanwhile innes and steele argue that ontological security is embedded in time and space where a self needs recognition and affirmation from others some research has explored ontological security in disasters such as haney and grayscholzs investigations into how emotional and social connections influence experiences of disruptions other research addresses the role of emotions in evacuation but not specifically ontological security although it is implicated to illustrate a study of 100 people in italy looked at emotional and behavioral responses after an earthquake including the emotional responses of fear worry and terror a study of 2400 people following the 2017 mexico city earthquake found that fear and surprise were the main emotional responses and that escape and protecting people were related to the shaking with evacuation actions occurring immediately after the shaking stopped a meager amount of research has explored the relationship between ontological security and peoples emotional responses following disasters specifically in aotearoa new zealand according to lindell et al such research focuses mostly on extreme and primarily nonexistent panic reactions where panic is understood as acute fear loss of selfcontrol and involves irrational or antisocial behavior lindell and colleagues found that following the christchurch earthquake in aotearoa new zealand rather than panic people were more likely to enact protective actions such as drop cover and hold on during shaking like us however harries argues that risk researchers should unpack the significance of emotions on disaster risk reduction drivers such as ontological security evacuation research research into evacuation behavior following earthquakes has largely overlooked emotions or feelings of safety as evidenced in the review paper by thompson et al much evacuation research has been imbued with behavioral response models such as those espoused by fishbein and ajzen these approaches consider how perceptions of a threat along with perceptions of the effectiveness of actions drive responses and focus on safety as a salient belief that facilitates preparedness and ultimately response actions for instance becker paton et al conducted interviews with 48 people living in three urban locations with seismic risk in aotearoa new zealand the study found that hazard beliefs preparedness beliefs and personal beliefs interact and influence peoples risk management actions many behaviorfocused models position human action as a rational decisionmaking process that can overlook the nuance of emotional contextual or socioeconomic influences while such models can provide useful insights into evacuation processes as argued in drabeks seminal work it is problematic to conceptualize people as decontextualized information processing units people are embedded in social systems that enable and constrain their ability to act while we focus specifically on feelings of safety and security we acknowledge that evacuation is a complex process that also involves social political and personal elements even with crossperil contextual differences certain elements are common across studies and can provide insight as to why people might evacuate these include perceptions of risk or threat environmental cues official warnings and other relevant information personalization of such information related to both the threat and action peoples ability to seek and confirm information prior experiences personal beliefs peoples knowledge and capacities access to resources and social influences also relevant are external drivers such as utility outages and whether neighborhoods or housing are accessible other considerations include age ethnicity cultural socioeconomic status type of dwelling location and socialpolitical standpoints which intersect to propel human action and therefore promote or hinder preparedness evacuation and response a few studies do highlight the role of emotion in evacuation decisions but studies have often focused on certain aspects or do not explore the role of emotion in much detail for instance a study of the influence of emotion on hurricane risk perceptions for people living in coastal areas of the usa conducted by demuth et al found that people have emotional impacts even without previous evacuation experience damage to property or economic loss emotional reactions alongside other variables heightened or decreased risk perception lindell et al compared the responses of people who experienced earthquakes in christchurch aotearoa new zealand and hitachi japan using a nineitem measure the responses were correlated with other contextual factors such as shaking intensity previous earthquake experience or disaster preparedness suggesting a correlation between shaking intensity and emotion responses despite the body of evacuation literature it is important to note that research that specifically investigates earthquake evacuation is limited this could be due to different approaches by countries in dealing with risk for example in aotearoa new zealand and in the usa advice is to drop cover and hold on during an earthquake and to shelter in place afterward rather than evacuate because infrastructure is generally sound in countries with less resilient infrastructure evacuation from buildings is promoted as a protective action a lack of advice on when and how to evacuate in some countries may have led to limited research on earthquake evacuation for these locations ergo it is important to study earthquake evacuation even in places where infrastructure is considered more resilient as research shows that potentially as many as half of a population may spontaneously evacuate after shaking in an attempt to address such gaps goltz and colleagues studied 12 earthquakes that occurred between 2005 and 2018 in eight different countries they described and analyzed how the different cultures and contexts influenced human behavioral responses including for actions such as evacuation a body of literature also exists on vertical evacuation for instance fraser and fraser leonard matsuo et al explored evacuation processes following the great east japan earthquake and tsunami they interviewed people directly affected about awareness response warnings timing and vertical evacuation finding height building construction community engagement signage and welfare centers were important to vertical evacuation as posited by fraser leonard murakami et al vertical evacuation with sufficient elevation provides lifesafety and is a necessary strategy for disaster risk reduction as an alternative to inland or higher ground evacuation vertical evacuation buildings provided safety for those in the inundation zone immediately after the 2011 great east japan tsunami in aotearoa new zealand the nema states that vertical evacuation should be the last course of action for emergency management groups vertical evacuation should only be used when not all can leave the tsunami zone due to conditions like short arrival times given there are limited studies on earthquake evacuation research on the evacuation experiences of innercity apartment dwellers during and after an earthquake and experiences of safety and security are also scarce research investigating disaster readiness more generally argues that the specificity of dwellings has an effect on preparedness and evacuation plans for instance surveys conducted in the usa including oakland county michigan and carteret county north carolina found that people living in multiunit dwellings were less likely to have emergency plans supplies or multiple evacuation routes survival items were not stored due to limited space although also argued by horney et al this could be partially attributable to cost conversely while trying to understand evacuation and emergency planning in dauphin county pennsylvania and bronx county new york usa survey data indicated that innercity dwellers are more likely to have an emergency response plan and survival supplies and that families living in apartments with more than five levels were more likely to have an emergency plan such findings need to be contextualized however in that apartment dwelling is more common in cities in the usa the research setting the following study explores evacuation processes directly after the 2016 kaikōura earthquake for people residing in apartments in the cbd area of te whanganuiatara the capital city of aotearoa new zealand at the time of the kaikōura earthquake an estimated 23000 people resided within the wider cbd however the exact numbers of people who lived in the cbd and who evacuated are unknown people evacuated voluntarily as media reports following the kaikōura earthquake evidenced illegally converted office buildings and transient groups complicated the evacuation and emergency welfare needs of residents the kaikōura earthquake occurred at 1202 am on november 14 2016 near te waipounamu aotearoa new zealand it involved a complex fault rupture that caused shaking for almost two minutes and was felt widely throughout aotearoa new zealand wellington experienced shaking ranging between three and seven on the modified mercalli intensity scale with the cbd enduring some of the highest levels of shaking in the region initially no tsunami threat was anticipated however 58 minutes after the kaikōura earthquake an official warning was issued by the mcdem the first tsunami waves reached wellington harbor approximately 30 minutes after the earthquake and continued for four hours the largest of the waves was recorded at a height of nearly 60cm approximately 70 minutes after the earthquake struck the immediate and ongoing aftershocks further compounded the earthquake and tsunami threat however the tsunami did not directly affect the cbd in terms of inundation or damage note this map use shakemap data to show the shaking levels among locations figure 1 shaking level map of the 2016 kaikōura earthquake by better understanding how ontological security influences evacuation and then return we aim to improve disaster preparedness and recovery for people who live in innercity dwellings this study was developed as a collaborative effort between the joint centre for disaster research the wellington city council the earthquake commission and the wellington regional emergency management office the first phase of the project involved developing a quantitative survey the freeresponse answers from this survey are presented in this article in relation to important evacuation considerations particularly how feelings of safety and security frame peoples actions recommendations on how to enhance evacuation processes for innercity residents if necessary in the future are then proposed materials and methods to undertake this research a team of researchers government workers and emergency managers collaboratively designed an online survey for people who live in the wellington cbd this codesign enabled the emergency management sector to identify community needs to increase earthquake resilience the survey was piloted through stakeholder engagement including representatives from the wellington city council and the new zealand earthquake commission it was piloted on a small number of representative organizations and consisted of both quantitative tickbox and likert scale questions as well as opportunities for qualitative freeresponse answers this study was conducted approximately one year after the kaikōura earthquake and followed the massey university ethical code of conduct the survey was uploaded into the online survey tool surveymonkey and was available for participation between 14 september 2017 and 24 october 2017 participants were volunteers 18 years of age or over recruited via advertising and a snowball sampling strategy whereby one participant recruited another the survey was advertised in forums that people living in apartments would have access to including body corporates and chairs group via email which was then circulated to extended networks innercity wellington pokapū o pōneke an advocacy group for residents and property owners in te aro and central wellington other residents associations including mount victoria residents association oriental bay residents association mount cook mobilized and thorndon association wellington city council webpage in 2017 wellington city council social media and facebook and the wremo facebook page upon completing the survey people were offered the opportunity to enter a draw for two prizes of a 1person grab and go kit these kits provide essential emergency items such as a flashlight with fm radio and a siren a total of 803 people responded to the survey of which 769 reported experiencing the earthquake more people identified as female than male eightyone percent of participants identified as new zealand europeans while other ethnicities were underrepresented especially māori people with higher incomes were more likely to answer the questionnaire as well as those living without dependents alone or with nonfamily only ten percent of people who responded considered themselves to be families with dependents ages ranged from 18 to between 88 and 97 the ages between 28 and 37 had the greatest number participants came from seven suburbs of wellington however most people reported residing in the suburb of te aro and wellington central with smaller numbers from other nearby suburbs most apartments were multistory with people living on a variety of levels the majority lived on levels 14 with the rest distributed up to 20 levels high the data was exported from surveymonkey into the spss software program and basic statistical and crosstable frequency analyses were undertaken on the numerical data for a more comprehensive analysis of survey questions response percentages and freeresponse answers please see becker et al 1 the survey questions and freeresponse answers were grouped according to peoples overall experience of the kaikōura earthquake their immediate responses to the earthquake and the tsunami threat and longerterm evacuation experiences these included questions about when and why people left and returned and their thoughts about past current and future preparedness any questions which provided freeresponse options for qualitative answers were analyzed and assembled into themes based on procedures used in thematic analysis as outlined by both braun and clarke and willig thematic analysis complements findings from quantitative analysis by providing further insights into experiences beliefs and intentions the first two authors manually searched for patterns of meaning in the survey by reading the freeresponse answers and interpreting these in an agreed way references to emotional responses and ontological insecurity were highlighted patterns were interpreted and four key themes were identified from the qualitative data shaking severity within a building building damage official warnings and aftershocks and social facilitation in seeking safety these categories form the core of the analysis presented below as part of the analysis quantitative data from the survey is also used to triangulate observations from the freeresponse data results shaking severity within a building feeling unsafe buildings depending on how they are engineered what materials are used in their construction and the height of the structure move during earthquakes in particular ways which impact peoples felt experience when the 2016 kaikōura earthquake occurred people reported feeling strong shaking that was intense enough to toss them about displace possessions destabilize their sense of ontological security and invoke fear to highlight some sample participants experiences include i was thrown against the wall and many objects fell out of the cupboards in the kitchen i was in bed and the noise made it sound like the world was ending outside i did not know what was happening it was not something i had experienced before and the experience was terrifyingunlike anything ive ever experienced and much worse than 2013and i thought i was going to die the building was moving so much that people thought they would not survive attests to the severity of the earthquake and their emotional response to the shaking of the building they were within it also reflects how when the physical world shakes our psychological sense of security can be shaken as well the ontological insecurity that eventuates in these situations is reflected here in reference to perceptions that the world was ending outside and the associated unnerving sense of uncertainty that comes when taken outside of ones everyday experience as giddens argues fear can be a response to a specific event the human desire for security and safety which is intimately entwined with experiences of being scared afraid or in terror is constituted by the primary emotion of fear for our respondents intense emotions combined with knowledge about potential risk or harm compelled them to act and in some cases was the primary driver for leaving their dwellings for instance two responses indicated that i was too frightened to stay the shaking had been so violent and there was so much glass i wanted to be somewhere where i would feel safer and lots of minor damage very scary had to evacuate due to emotional stress it appears that fear and stress were their motivators to evacuate in these extracts ontological insecurity manifests in experiences of being too frightened to stay and in efforts to restore a sense of safety and security by moving to a place where one could feel safer and in doing so restore a sense of ontological security in this sense physical evacuation is entangled with the desire for psychological evacuation and fear management of the total freeresponse comments over a third indicated being cautious afraid or too scared to be in their apartments as the underlying reason for evacuating in this way the relationship between emotional distress and being unsafe was a driver for action however it is necessary to note that fractured constructions of safety due to experiencing disasters do not always engender risk reduction actions even when anxiety is increased in aotearoa new zealand earthquakes also pose a tsunami risk for coastal areas as transpired with the 2016 kaikōura earthquake as such there have been numerous education campaigns aimed at teaching people that a long or strong earthquake is a natural tsunami warning here the duration or strength of an earthquake should be the key driver to evacuating to safety rather than any experiences of ontological insecurity therefore even if people residing in tsunamirisk areas feel safe they should evacuate immediately to higher ground or further inland and not wait for an official message however for the 95 people who gave a primary reason as to why they evacuated their buildings only thirtyone percent reported the reason was because of the risk that there might be a tsunami the immediate inaction by many in this study suggests that people were either not aware of the tsunami threat or of what to do were not concerned about their wellbeing or felt safe enough to stay in their apartments this proposition is supported by thirtyfour percent of people who did not evacuate agreeing or strongly agreeing with the survey question that they were confused as to whether to stay or leave the city center only twentyfour percent of respondents who evacuated immediately stated they went to higher ground to avoid a tsunami even though approximately half of the suburbs surveyed were located in a tsunami evacuation zone only two freeresponse answers mentioned vertical evacuation although this is an important strategy i led vertical evacuation with others from lower floors to higher floors within the building before the tsunami warning my main concern was that tsunami evacuation advice didnt cover apartment dwellers very well i decided that someone on an upper floor of a robust modern building several blocks from the coast would be safer staying put than going down to ground level and walking a km or more through potentially dangerous streets to higher ground the standard advice to always seek higher ground if youre near the coast doesnt specify what near means and doesnt weigh up the potential hazards of leaving your building these excerpts highlight how prior knowledge is useful during times of distress and that targeted evacuation messaging is important to the specificity of the inundation zone and highspeed larger tsunami waves it is not clear if people tried to evacuate during the shaking although our survey demonstrates that thirtyeight percent evacuated immediately after the earthquake suggesting they evacuated after the shaking stopped however once people decided to evacuate they then needed to determine where it was safe and how to go to that place of safety in the absence of official guidance randomness seemed to prevail for many regarding where they evacuated different people chose different places to seek safety and security some reported going to a random street somewhere as there was no guidance or welfare center while others drove up the hill and sat in a parked car people talked about going to open spaces outside buildings so as to avoid falling debris if that was the case others reported evacuating to friends homes where people moved to find refuge and security was dependent on their location knowledge of the risks that staying inside or being near their buildings posed and social and material resources for instance only a small proportion of people evacuated to paid accommodation a second residence or an official emergency assistance centre some were able to go to accommodation arranged by an emergency welfare team of those that left their apartments to stay elsewhere the majority evacuated to premises close by with eighty percent staying within wellington and fifteen percent within the wider wellington region these findings highlight that we need to encourage people to consider alternative accommodation in the event of evacuating or not being able to stay in their apartments the findings further remind us about the importance of clear and precise risk communication so people know how to act even when ontological security is not jeopardized as argued by the undrr a government is responsible for the appropriate dissemination of information about hazards and disaster risk reduction actions based on good research and the right communications platforms that target the particular needs of an audience building damage is my dwelling safe compounding emotional responses of fear and ontological insecurity was the damage caused to buildings and other property by the ground shaking a number of sources reported that there was immediate damage to structural and nonstructural elements of buildings in the cbd of the fortyfour percent of respondents in this research that reported apartment damage some noticed immediate damage to both structural and nonstructural elements of their buildings these respondents were also concerned about other damage such as breakages of household items and movement of furniture twentysix percent stated that they evacuated primarily because of structural or property damage together with feeling unsafe because of that damage only thirtyseven percent of respondents indicated they were aware of an emergency plan for their building the excerptsdid not feel safe to stay in the building there were cracks everywhere and we werent sure how severe the damage was thought the building would come down and i evacuated because i didnt know how badly the building had been affected and i didnt know if it was safe to staytypify peoples lack of knowledge about how to manage their concerns about building safety these respondents provide cues to ontological insecurity and the need to leave because of the visible physical damage to their building and uncertainty regarding the extent and seriousness of this damage unsafe buildings became a physical manifestation of the tenuous existential conditions in which people were placed by the earthquake building assessments were necessary to bring certainty to the situation by determining which buildings were structurally sound safe to enter occupy or reoccupy however due to the large number of buildings that needed assessing this took time so people remained in their buildings even if they were concerned if they had no other options or if informed otherwise most people were out of their apartments for up to 24 hours however twentythree percent stayed out of their apartments for 23 days and ten percent were out for a week of those that were out for more than a week not returning was due to their being afraid or due to their building suffering significant damage those who had to stay in their building while not knowing how safe it was experienced further disruption to their sense of ontological security in this context people had to live every day with uncertainty about personal safety even though they were worried for instance people reported that they just needed to know my building isnt going to collapse living in buildings that had not been assessed for safety and therefore could potentially cave in meant not knowing if lives were at risk and amplified the negative emotions that accompany ontological insecurity intersecting this and anchoring the fear of harm was the february 11 2011 christchurch earthquake where 185 people lost their lives the ongoing effects of that earthquake and the recovery process are well etched into the ethos of aotearoa new zealand and continue to influence collective responses to earthquake events that is human beings not only react to the actions of others but appear to learn from and construct our own experiences of particular events in relation to the previous experiences of others during similar but distinct events the relationship between the christchurch and the kaikōura earthquakes is evident in the following excerptsfear of building collapse like christchurch terrified of collapse like ctv building in christchurch i am originally from christchurch and feel safer outside and i evacuated because of emotional stress detailed knowledge and experience of christchurch earthquakes and deaths in multilevel buildings vicarious and lived trauma from the christchurch earthquake where design failings of the ctv building meant it collapsed and killed 115 people were experienced by these innercity residents knowledge of buildings collapsing reified disaster risk and weighed on peoples minds influencing emotional responses and actions as argued by zaretsky when trauma is an event that occurs externally to consciousness it can disrupt existence and tear at the fabric of society in ways that conscious experiences do not in these situations a rupture to ontological security is a collective rupture to the psyche outside of existence in the everyday these ruptures also manifest through global reporting of other natural hazards and personmade events for instance the horrors of the 24story grenfell tower fire in the united kingdom in 2017 where 79 people died were recalled by the following respondent and as such would precipitate future evacuation action noise level was deafening and we could not be sure a fire had not started as the shaking was so severe after grenfell tower i do not think i would stay uncertainty about safety is clearly articulated here and consequently the respondents selfevacuated from their apartment others were told to evacuate and wait until engineers had assessed building damage before returning to apartment buildings which they duly did however even when experts had checked building safety and reassured residents feeling unsafe still influenced peoples return actions one person indicated that even when officially advised that it was safe to return they did not as they continued to feel unsafe in this situation an official safety assessment did not alleviate feelings of insecurity and fear here it can be surmised that ontological security and preearthquake homeostasis had been seriously disrupted while trust in the reliability and consistency of the world had not returnedthere was no longer a secure base distrust of institutional power perhaps as another effect of the christchurch earthquake grenfell tower fire or other tsunami events are also reflected in the above text research by hommerich found that trust in institutions was low in japan primarily because of the way in which governing bodies dealt with the aftermath of the great east japan earthquake tsunami and nuclear meltdown in this research sixtyone percent of the respondents who were officially asked to evacuate indicated they felt neutral when questioned if they felt supported by officials these concerns might affect future evacuation decisions as the following quote demonstrates it really concerns me how little open green space there is in the cbd for residents evacuating apartments what if everyone needed to camp out for several days it also really concerns me that the council has recently agreed to increase housing density in the cbd and increase height limits on new apartment buildings this is crazy given the earthquake risk and past wellington quake experiences an expression of concern towards institutions that act in crazy ways because of the potential to overpopulate the cbd demonstrates how powerless some people feel about what is happening to their environment greenspace is like a personal backyard for innercity residents and camping out would enable a place of safety after an earthquake limited innercity free space means that this might not be possible and was therefore troubling this finding was supported by research commissioned by the wellington city council in that people who moved away from the cbd cited the lack of outdoor space as a reason in wellington the city council had used building safety rating stickers to denote buildings earthquake risks and these stickers influenced peoples actions such as evacuation return or moving due to feeling unsafe the safety rating stickers were initially put in place following the christchurch earthquake in 2011 several years before the kaikōura earthquake a yellow sticker warned that a building was earthquakeprone with 15 years to strengthen or demolish a number of people explicitly stated that they evacuated because of the presence of a yellow notice on their building which can be interpreted as feeling unsafe for instance respondents indicated as a result of the earthquake we actively started looking for a rental house and have subsequently moved out of the yellow stickered apartment we were in at the time we evacuated during the earthquake because our building has a yellow notice we went back in because we only had underwear on and … we literally had to move out as the property the landlord was living in was yellow stickered so he moved back to this property the first response demonstrates how leaving a yellow stickered building can take time and planning the second response implies that participants immediately evacuated the building due to its poor earthquake rating but returned because even while they might be worried about safety they were unprepared the third response highlights the rippling social effects of material inequality and building resources although this person was not residing at the property that was yellow stickered they still needed to move because of the landlords sense of ontological insecurity as the wellington region is bisected by several active earthquake faults a large number of public information efforts have been conducted by a range of civil defense emergency management groups to encourage people to be earthquake prepared it was not only the severity of shaking within buildings during the initial kaikōura earthquake but also building damage or the strength of the building that led to feelings of being unsafe and evacuation action official warnings and aftershocks also triggered experiences of insecurity and contributed to people evacuating official warnings and aftershocks more reasons to seek safety while the survey questions did not ascertain specific information about official warnings the qualitative responses indicated that official warnings had an effect as mentioned previously an official warning was generated for the tsunami threat but other warnings pertained to the activation of fire alarms a number of people indicated that they evacuated immediately after the earthquake because a fire alarm or siren sounded which for some was perceived as a form of official advice rather than any sense of being unsafe while for others it increased feelings of ontological insecurity and therefore spurred them to leave it is evident from these respondents that ontological insecurity was triggered by uncertainty about feeling unsafe and the risk of fire after the alarms sounded however these fire alarms also became a burden as several respondents complained that they continued to ring incessantly due to fire services being too busy to attend and turn them off traditionally the aim of all official warning systems is to communicate risk and encourage people to take action to reduce harm to themselves and others in some instances the persistent wailing of the alarms added to respondents sense of frustration uncertainty and risk of harm as the following excerpt suggests because our fire alarm was activated we had to evacuate into a possible tsunami threat fire alarm went off in the building and couldnt be turned off we sat on the road outside till 3 am till we were allowed back into the building there could have been a tsunami evacuating buildings and waiting on the roadside placed this respondent in the path of a potential tsunami however despite these concerns they remained there for hours nineteen percent of respondents indicated that they simply moved to the roadside outside their building when they evacuated thereby potentially putting themselves at risk of harm from a tsunami that there was a time delay in shutting down alarms is also concerning because we can assume that fire suppression activities would have been compromised for these buildings cousins et al and more recently scheele and horspool warn that fire conflagration is an extremely viable phenomenon in wellington with its numerous fire ignition sources such as reticulated natural gas piped through the central city and infrastructure and water supplies being located on fault lines although as postulated by wellington lifelines group the effects of a fire depend on building construction and density wind velocity firefighting response and seismic activity conversely other respondents interpreted the lack of a tsunami siren warning as an official message that there was no tsunami risk with no official warning and lived experience of the christchurch earthquake the following respondent did not feel ontological insecurity and was able to return to sleep indicating that they woke up wondered whether we should evacuate for a tsunami figured the sirens would sound went back to sleep id lived in christchurch through much worse earthquakes so it was no big deal it is important to note that the wellington cbd has no official tsunami siren system tsunami warnings are communicated via social radio and television media problematically for this event however there was a long delay before the tsunami warning was broadcast because the earthquake epicenter was located far inland and the magnitude and complexity of the fault rupture were initially underestimated the long delay reiterates the importance of heeding the natural warning it also challenges previously adhered to knowledge about earthquake epicenters needing to be offshore to trigger a tsunami and implies better engagement with the public is necessary to help with their understanding of scientific risk uncertainty as well as alarms and sirens the severity of the ongoing aftershocks caused great concern with many respondents articulating how their experience of the aftershocks influenced what actions they took in response they stated evacuated for two nights too noisy and too unsettling we were feeling aftershocks constantly and didnt feel safe in the flat the floor was bouncing up and down as well as the building moving side to side i didnt like that so chose to leave my apartment after the first two big aftershocks and go to my sisters onestory wooden house nearby instead …the aftershocks were severely felt in the apartment with the movement of the building and it was decided by the residents in our flat relocating to kelburn would help us feel safer and more able to get some sleep and we were never evacuated and our building was assessed as safe to stay in my flatmates ended up moving out soon after due to the stress of aftershocks it makes sense that there were a number of survey responses that expressed being afraid of the aftershocks and concern about the effects of large aftershocks on building safety in these instances ontological insecurity was disrupted by alarms and buildings that were earthquakeprone as well as aftershocks four months after the 2011 christchurch earthquake dorahy et al found that aftershock anxiety significantly influenced psychological distress in people these aftershocks reinforced experiences of stress fear and depression and played a particularly important role in decisions to stay evacuate or return for some the aftershocks were constant material reminders that the world was not safe the situation was complicated by people not knowing what to do or how to respond one person suggested that information in apartment blocks just says drop cover and hold on when an earthquake strikes thereby focusing on an immediate response during shaking but disregarding what to do when the shaking stops diverse opinions emerged among the respondents about whether it was safest to stay inside after an earthquake or whether people should evacuate outside suggesting another knowledge gap for some living in an apartment deemed earthquakeprone motivated an initial evacuation after shaking had stopped however for others social connections such as neighbors not evacuating facilitated reentry and ongoing aftershocks triggered further evacuations participant responses foreground the importance of ongoing situational and social dynamics that may intersect with ontological insecurity and precluded decisions to leave and return in response to events social facilitation in seeking safety should we go stay away or return it was evident that evacuating and returning to ones building were complex activities that were influenced heavily by a range of contextual factors including a primary desire for restoring ontological security in this way selfevacuations occurred based on decisions made by residents for themselves and due to social cues people reported evacuating because their neighbors did while others took advice from family members to evacuate to higher ground because they live on the coast these responses mirror findings from warning models where it is assumed that people seek others to confirm and respond to threats thirtyeight percent of people in this study reported evacuating because of advice from other people while fortysix percent agreed or strongly agreed that prior to evacuating they looked to others in their apartment community to find out what to do the following response highlights how some people left not only because of the physical damage they could see to their buildings but also because neighbors did my apartment was badly damaged and unsafe to sleep in due to toppled furniture and lots of broken glass we evacuated due to the alarming large cracks in the flat our neighbors were evacuating so we decided to social capital the social ties that bind people together can enable better recovery after a disaster as people are able to work together and share resources half of the respondents who evacuated were able to go to a friend or family members house however social facilitation can also produce less favorable outcomes as was seen when people stayed in their apartments after following the actions of their neighbors a key social element that influenced peoples feelings of safety and decisions to evacuate was not wanting to be alone twentyeight percent of respondents indicated that their primary reason for evacuating was community connection individuals often gain some sense of ontological security from being with others and from mutual support people who felt alone in their apartments were more likely to feel unsafe and looked to others for social support in other words being alone increased ontological insecurity and feelings of fear as represented by the respondents who stated felt unsafe alone too afraid to stay there alone and i was alone that night in my apartment and was scared so badly and had no idea if i was to evacuate or stay thank god that my apartment was safe and i have lots of friends checking on me but this is not ideal to find mutuality people evacuated and had friends check on them although as articulated this still was not ideal it proved to be only a limited strategy in terms of regaining a sense of ontological security for example where extended periods were spent away from their apartments respondents reexperienced feeling unsafe and fearful particularly if separated from support networks by themselves or out of routine those that did not return to their building sought refuge with family or friends or considered returning to their buildings when people selfevacuated they were encouraged by others to join them at their residences my building was checked on the same day and we were told it was safe but i left to be with my family in auckland i felt safer at my boyfriends house rather than alone in my apartment i was home alone and all our stuff had fallen over and i didnt feel safe being there so my friends came and got me respondents reasons for evacuating were associated with their need for connectionto experience social capital and connection is important when people endure forms of trauma that rupture their sense of a stable life we can assume that the need for safety was a key driver when people were asked what motivated them to return to their apartments fifty percent indicated safety as the primary motivator in that they felt safe enough to return social relationships were also mentioned as a reason as some respondents worried that they were being a burden or disturbing family or friends by staying with them for too long even though they were feeling unsafe some indicated did not really feel safe returning but inconvenient to stay with friends any longer aftershocks were unnerving i didnt want to inconvenience others for too long returning from evacuation was a complex process of managing personal emotional experiences and needs with those of others especially for those that had to evacuate for longer periods of time approximately seven percent indicated that they did not return to their apartments over a longer period of the respondents who were out longer than one week eight reported being afraid to return as the primary reason one percent of people were still not back in their apartment as of october 2017 when the survey was undertaken further notable influences on evacuation return and ontological security were having nowhere else to go or simply wanting to clean up their apartment without suitable social relationships or material or financial resources people had limited agency and returned to their dwellings even if they were afraid were precarious or unsafe any rupture to ontological security can also be repaired by being surrounded by familiar places and when going about every day habitual actions as is the intersectional complexity with evacuation return is also influenced by other elements for instance thirty percent of respondents cited the need for a routine as a reason to return people also reported that they returned to live in their apartments because their workplaces had reopened work deadlines were looming and they needed to be in close proximity to work being permitted to return and inconvenience were also important drivers conclusions our qualitative survey data from wellington cbd residents following the 2016 kaikōura earthquake suggests that consideration and experiences around safety and ontological security influenced whether or not people evacuated from apartment buildings and when they would return our findings are a divergence from and add to previous studies that focus on quantitative behavioral response models they also aim to add to the small body of literature that explores the influence of emotions during and following earthquakes we provide an important context beyond current hypothetical modeling which positions peoples evacuation actions on external drivers such as a buildings structural integrity ability to access utilities or lifeline services and whether the neighborhood is accessible and inhabitable such drivers are important and we recognize they do contribute to peoples actions however our research highlights peoples need for ontological security the desire to feel safe as a key motivator that is absent from models and approaches that overly rely on the assumption that people act rationally rather than emotively many of our respondents described feeling fearful and anxious and sought support from other people at the time of the initial earthquake and during the aftershocks not feeling safe involved concern about personal wellbeing and the safety of the building it also involved vicarious and lived trauma from the 2011 christchurch earthquake a range of issues occurred with official warning systems that in turn influenced peoples emotional responses these covered continuous activation of fire alarms so there was no official warning and people turned to each other for cues as to what they should do many respondents reported feeling confused and insecure because of the alarms highlighting the need to address the use or meanings of an alarm so they do not continue to cause problems for apartment dwellers into the future there was a significant degree of randomness in terms of where people sought refuge at the time of the study some people remained unsure about whether to stay in the cbd or leave those who had returned had done so due to a lack of other options or not knowing what else to do as well as the need for routine safety and convenience in this instance safety and security was also a driver this research has demonstrated some of the unique challenges that cbd residents in wellington aotearoa new zealand experience it foregrounds the need to attend to the specificity of innercity residents preparedness and mitigation engender awareness of what to do with a natural or official warning and provide information promptly this is crucial for people to feel at ease if they stay or know when to evacuate what to do if they evacuate and where they should go if evacuation is necessary officials need to advise people of the locations of accessible places of safety it is additionally vital that we work towards strategies that enable people to have knowledge about the safety rating of their buildings it is also prudent to consider a range of potential evacuation scenarios to support the wellbeing and safety of people residing in apartments in cbds while the ground shaking from the kaikōura earthquake in wellington was strong it caused moderate effects and future events may be more severe we must also pay attention to the diverse range of people that live in cities and their diverse experiences and interpretations of ontological safety we recognize that the majority of respondents in this work selfidentified as european with higher incomes and without dependents as such future work in preand postdisaster innercity contexts should engage in ways that are accessible and culturally specific to multiple communities which often feature highdensity living arrangements by engaging in inclusive research that values diversity alongside the complex array of emotional and contextual elements we can produce more comprehensive knowledge about evacuation actions in summary it is imperative that local authorities emergency managers building owners building managers and body corporates consider preparedness planning and evacuation that encompasses the range of drivers for human action such as the need to feel the world is continuous secure and safe this could include bespoke preparedness messaging and clear advice around the effects of immediate emotional psychological and contextual elements and how to manage them the wellington city council has identified significant innercity intensification over the next 30 or so years whereby the city will need to accommodate approximately 7000 new households accordingly it is necessary to engage in disaster risk reduction through a sustainability lens to build cities that generate good health wellbeing and a sense of place in the everyday ordinariness of life as well as within disaster events it is through engaging in prior risk reduction and sustainability actions that peoples emotions and ontological security can be supported during emergency events

this research explores the ways in which safety and emotion were drivers of evacuation for people residing in highdensity innercity housing in the central business district of te whanganuiatara wellington following the 2016 kaikōura earthquake drawing predominantly on qualitative freeresponse answers from a survey of 803 people approximately one year after the kaikōura earthquake the study argues that ontological insecurity was a key driver of peoples actions key themes identified in relation to ontological insecurity and emotional responses were the severity of the shaking and how it was experienced the building damage official warnings the ongoing earthquake aftershocks and the social actions of others this work argues that with the ongoing growth in highdensity innercity living disaster risk and emergency management should encompass preparedness response and recovery strategies that include emotional responses and social processes while valuing the specificity of innercity living

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introduction pediatric cancer will affect 10470 children under the age of 15 in 2022 alone in the us and it is one of the leading causes of death by disease for this population group alongside congenital malformations and intentional selfharm 12 despite improved treatments and longer life expectancy the challenges for pediatric cancer patients are ongoing and lifelong they struggle daily with debilitating early and late side effects including pharmacogenomic variations with drug exposure pain fatigue psychological problems fear of cancer recurrences cognitive difficulties social problems and other quality of life aspects 2 racial and ethnic groups disparities are present in the rates of the most common types of childhood cancer with hispanic children having nearly twice the rate of leukemia as black children 3 like all cancers gene mutations and alterations lead to uncontrolled cell growth and eventually malignancy these genetic changes are passed down from parent to child whose family history risk factors and prior exposures further enhance racial and ethnic disparities for pediatric cancer these disparities increase childrens vulnerability to the development of psychological and physical disorders which may directly or indirectly affect their general clinical condition the diagnosis and treatment of childhood cancer causes physical and emotional suffering not only for children but also for parents caregivers and their communities 34 there is a growing movement and awareness of treating cancer patients in a holistic approach pediatric cancer patients can partake in integrated medicine care which incorporates conventional medical treatments along with different types of complementary therapies animal assisted interventions is blanket terminology for this type of therapy including animalassisted therapy animalassisted activities animalassisted education and aai resident animals 5 thus aai could mitigate the arduous physical and psychosocial symptoms for cancer patients research on humananimal interaction especially as it relates to pediatric cancer is limited recognition of aai as an innovative adjuvant therapeutic modality its safety and efficacy in different environments including oncologic hospitals is growing one of the main obstacles in a wider implementation of aais in the clinical settings is the concern about zoonoses and possibility of infection transmission from the therapy animal to the child patient 46 the evidence of transmitted zoonotic pathogens in this context is scarce furthermore research on susceptibility to zoonoses associated with dogs for minority groups in the us is almost nonexistent the aim of this review was to synthetize the available data on the most common human infections from therapy animals and their risk factors for pediatric oncology patients particularly for minority groups of patients the emerging findings can help improve existing hospital and clinic animalassisted therapy protocols with the dogs undergoing health checks for often overlooked pathogens resulting in safer therapeutic environments for children with cancer guardians and staff materials and methods for this paper we conducted a scientific literature search performed thorough may 2021 examining the following databases pubmed psycinfo web of science cumulative index to nursing and allied health literature scopus cochrane library the search used mesh terms and included all possible combinations of keywords from the following 4 groups animal assisted therapy pet therapy animal assisted intervention or human animal interaction cancer neoplasm or tumor children adolescent or pediatrics and race or ethnic background we selected articles describing animalassisted intervention with pediatric cancer patients as well as articles mentioning racial and ethnic characteristics of pediatric cancer patients the articles obtained were screened for relevance and selected based on the abstracts and their relevance for the scientific literature furthermore we performed a cited and a reference list resulting in additional articles all relevant articles included were in english results aai and pediatric cancer a diagnosis of childhood cancer has debilitating consequences for children families and their communities the demand for a holistic patientcenter treatment includes incorporating complementary and alternative adjuvant therapies such as animalassisted interventions this terminology encompasses animalassisted therapy animalassisted education animalassisted activity and more 5 the most common animals used for aais in clinical settings are dogs despite the history of humananimal interactions research on aai is still in its infancy studies on aai in the pediatric oncologic context are scarce with only eight known studies conducted internationally four of these studies were done in the us emerging evidence reports beneficial effects for patients with phycological and physical diseases the unique humananimal bond is believed to facilitate positive changes in patients emotional behavioral mental and physical status 7 8 9 10 11 12 13 14 15 16 the presence of animals can lead children to have a more favorable perception of the hospital environment increasing their participation and enhancing their displayed affect 8 shortterm improvements were found in childrens functional autonomy such as feeding and nutrition following aai sessions 910 results also showed higher heart rates in children participating in aai compared to children in nonpet therapy groups but also noticeable pain alleviation decreased fear and discomfort felt during medical procedures and cancer treatments 8 9 10 mccullough et al noted improvements following aais in the initial stages of pediatric cancer treatment with children experiencing significant reduction in anxiety and parents reporting significant decrease in parenting stress 11 hospital staff parents and guardians recognized positive changes following aai including enhanced calmness motivation and better interpersonal relationships between healthcare professionals and patients as reported by questionaries of the medical staff in an italian study and qualitative analysis in a brazilian study 812 reported longterm outcomes in children that took part in aai include improved selfesteem treatment compliance and motivation patients reported being more optimistic about the future evidenced by a positive correlation between happier mood and higher cortisol levels moreira et al noted a reduction in stress anxiety loneliness and isolation following aai sessions 12 on the other hand mccullough found no significant difference over time between patients exposed to aai and those who were not 11 novel intervention using virtual aais sessions promoted wellbeing improved connection and friendship among pediatric cancer patients 13 aais can contribute to improving the overall quality of life in children experiencing cancer by decreasing pain and fear providing a muchneeded distraction from the gruesome reality of cancer treatments and procedures lowering emotional distress and facilitating symptom management 4612 zoonoses associated with dogs despite approval and recognition of the beneficial effects of aai parentsguardians requested additional safety issue facts and information 8 pediatric oncologic patients due to their immunodeficiency status are at higher risk of developing disease or complications from zoonotic diseases furthermore parents and staff lacked adequate knowledge on the implementation of aais as well as insufficient understanding of the therapeutic objectives of animal assisted therapy with pediatric cancer patients 12 in this context the close interactions between humans and animals increases the risk factors and can facilitate the transmission of potentially pathogenic microorganisms from animals to patients exposure can occur through inhalation and contact with skin eyes and mucous membranes transmission occurs through direct contact inhalation of aerosols infected saliva contaminated urine or feces or contact with contaminated objects 17 18 19 common transmissible diseases associated with dogs include viral infections bacterial infections fungal infections parasites and visceral larva migrans 17 18 19 20 for the majority of zoonoses effective treatments are available basic preventive care protects both canine and human health and is further enhanced by animal and environmental management control epidemiologic studies on the topic suggest that the occurrence of dog associated zoonotic disease is low overall 19 results from an italian study showed that 316 of the animals involved in aai over a twoyear period positive for pathogens with 217 of the dogs harboring potentially dangerous zoonotic parasites 7 availability of educational resources and open communication about zoonotic diseases for medical staff dog handlers and patients is critical and ensures good practices it also builds trust between patients aai teams and medical staff the surveillance of zoonotic pathogens in the context of aai is necessary for ensuring a safe environment in the clinical setting for patients staff and families prevention methods for zoonotic diseases vary for different pathogens however standard preventive measures are recognized as effective tools in reducing the risks of exposure and transmission susceptibility to zoonoses by race cancer is the leading cause of death by disease past infancy among children in the united states among children ages 0 to 14 years it is estimated that in 2021 10500 will be diagnosed with cancer and 1190 will die of the disease 3 within the pediatric population regarding racial and ethnic minority children we found that compared to nonhispanic white childhood cancer patients black and hispanic patients had worse survival for all cancers combined leukemias and lymphomas brain tumors and solid tumors 21 22 23 24 25 black and hispanic patients had a higher risk of death compared to white nonhispanic patients black patients had a higher risk of death at 5 years after diagnosis compared to nonhispanic white patients with a 5year relative survival rate of 698 for black patients 729 for hispanic patients and 776 for white patients 21 22 23 similar differences were found when comparing 125year survival rates 24 marcotte found the incidence of leukemias to be higher in white children when compared to both black and asianpacific islander children 25 despite similar reported survival rates for hispanics african americans asians and white children gaps in understanding disparities in cancer still exist 2627 racial and ethnic disparities in childhood cns tumor survival appear to have their roots at least partially in postdiagnosis factors potentially due to the lack of access to high quality care leading to poorer overall outcomes 2829 these disparities include differences or delays in treatment black race hispanic ethnicity lack of private insurance and adolescentyoung adult age are most often associated with these poorer outcomes 26 additional disparities include impaired access to care and clinical trials differences in cancer biology treatment nonadherence language barriers and implicit racial bias although socioeconomic factors may account for a large proportion of disparities seen the causes of disparities are complex and interconnected and still need to be better understood 2728 further studies on how systemic racism and oppression impact pediatric cancer are needed prior research suggests that ethnicity is a crucial factor shaping disease knowledge 30 hispanicslatinos have 30 less knowledge on rabies compared to nonlatino whites counterparts language and cultural barriers the lack of available educational materials in languages other than english for transmissible infectious diseases all play a role furthermore african american people have lower knowledge on rabies than their white counterparts in this case trust in the information source was a key factor with african americans having low or diminished trust in public health authorities women also scored higher on knowledge about rabies than males 31 health disparities are a heavy burden on the us healthcare system with racial and ethnic differences in chronic disease morbidity and mortality well documented nonhispanic blacks and hispanics exhibit odds 17 times and 28 times higher than those of nonhispanic whites for contracting enteric pathogens 32 nonhispanic blacks were almost twice as likely as nonhispanic whites to be seropositive for helicobacter pylori and mexican americans were 22 times more likely to be seropositive than nonhispanic whites this higher prevalence of infection for minority groups is also reported for toxoplasma gondii hepatitis b virus hepatitis c virus herpex simplex2 32 these disparities are inherited by minority children and hence by minority pediatric cancer patients combined with the immunocompromised status as a result of cancer treatments the prevalence for infections for minority pediatric cancer patients increases considerably existing hospital protocols for aais perhaps in part due to broad media claims of patients benefits canineassisted interventions are becoming more popular in hospital settings 33 states including illinois have established policies for aai based on cdc recommendation regarding establishing a department in charge sanitation and infection control certification of training patient screening for participation areas permitted length of sessions type of animals policies for incidents and patient consent 34 despite the existence of these proposed guidelines for aai in hospitals there are significant differences in infection control policies across these groups 35 additional research is needed to investigate whether therapy animals can serve as pathogen vectors from being contaminated by contact with one patient and then transmitting these pathogens to another patient leading to pathogen exchange this is critical to test because many patients served by these therapy animals have a compromised health status and may be at higher risk of infection compared to the general population 36 chuback and hawkes reported on the variability of practices and protocols used across institutions these differences in protocols and intervention designs could potentially compromise the outcomes safety and generalizability of findings 14 current guidelines recommend that the following 10 healthrelated factors be evaluated at each life stage for a canine patient lifestyle effect on the patients safety zoonotic and human safety risk behavior nutrition parasite control vaccination dental health reproduction breedspecific conditions and a baseline diagnostic profile 3738 findings of aai studies with pediatric cancer patients show a lack of standardization of the number of canines duration and frequency of sessions the executed activities and the safety measures for the animals and cancer patients lefebvre et al advocated the need for universal consensual and collaborative guidelines that represents the interests of the stakeholders in the pediatric cancer arena which provides specific recommendations to minimize both injuries and the transmission of infectious organisms to and from therapy animals 37 38 39 the guidelines developed recommended a lessthanrigorous screening protocol to identify animal carriage of specific pathogens exceptions were made for cases when the animal interacted directly with a human carrier or if the dog is linked to an outbreak of infectious diseases 39 silva and osorio proposed and implemented an effective aai protocol for outpatient pediatric oncology patients in brazil patients were screened for severe infections such as infection by resistant bacteria or suspected or confirmed infection with clostridium difficile no details are provided on what infections the therapy animals were screened for 16 santaniello et al reported on the presence of p multocida in dogs performing aai highlighting the potential risk of this infection being transmitted from therapy animals to vulnerable individuals including immunocompromised patients 40 furthermore results of a systematic review emphasize the need for mandatory microbial control of the therapy animals along with strong hygienic rules considering the evidence of increased risk of zoonoses associated with dogs for eskape pathogens 41 studies show a lack of effective educational campaigns and open communication networks between hospital infection control departments and therapy animal handlers regarding infection risk 36 expanding and improving infection control measures for aais in cancer hospitals and clinics is critical to obtain a positive balance of the benefits and risks for all stakeholders 4243 discussion historically african americans have had the highest death rate and lowest survival rate of any racial or ethnic group for most cancers although there have been improvements in recent years persistence of systemic racism oppression lower socioeconomic status impaired access to health insurance and adequate medical care services support existing health disparities manifested in african americans still being the populational group with the highest cancer rates nonhispanics have also a higher risk of death compared to their white counterparts 13 pediatric cancer is one of the few cancer types where the discrepancies in cancer incidence are lower black children experience decreased incidence of acute lymphoid leukemia compared to whites and this decreased incidence was strongest at ages 1 through 7 years hispanic children have a decreased overall incidence of hodgkin lymphoma and astrocytoma but experience increased risk of acute lymphoblastic leukemia compared to nonhispanic whites substantially decreased risk across many tumor types was observed for asianpacific islanders and american indianalaska natives pediatric cancer patients 3 21 22 23 24 25 despite these encouraging statistics health disparities impacting minority groups are also affecting children experiencing cancer a cancer diagnosis has major repercussions not only for the child who is diagnosed but also for his immediate family and caretakers systemic oppression racism financial burdens all play a role in increasing the disease burden for disadvantaged and minority groups of patients furthermore prior evidence suggests a higher susceptibility to infections for hispanics and blacks a canadian study showed that therapy dogs visiting hospitals have almost five times higher odds of carrying mrsa than therapy dogs who visit other locations such as schools 43 compounding the immunodeficient health status of pediatric cancer patients their risk for zoonotic diseases increases mitigating the zoonoses risks requires all aai stakeholders in a clinical setting to collaborate and have accurate and timely information on infection diseases 19 previous studies have not reported any serious negative impacts of aai and most report at least some positive effect on the patients and families several studies speak of the benefits of aai chiachun et al 44 in a study of childrens systolic blood pressure when measuring sbp before and after aai reported decreased levels from before to during and continued after the aai interaction 45 lindstronnilsson et al found the wellbeing of children increased to very good after aai and reported the hospital stay as better with 93 of the children assessing their interaction with the dog as very good 45 zeblisky and jennings reported similar results at a large childrens hospital data from a 9year study indicated a 93 percent positive change in the mood of patients 46 avilaalverez and pardovasquez concur as children and parents gave aai their highest satisfaction rating with a significant improvement in the childs mood 47 in a survey of parents and staff at a childrens hospital uglow reported that out of 200 respondents 100 recommended expanding the services across the uk and had no concerns of the dogs being present their behavior or cleanliness 48 concerns of disease transmission may be better addressed with the active involvement of veterinarians currently in many hospital settings the veterinarian role is limited to requests made by the pet owner for participation based on hospital policies expanding that role so the veterinarian is an active member of a team that includes hospital staff the individual responsible for care of the animal would enhance the ability to focus on the wellbeing of the pet possibly mitigation of the spread of disease and enhance the ability to maximize the benefit of the aai 3738 to assist veterinarians working with animals participating in aai products such as wellness health care checklists could facilitate communications between the veterinarian and client relating to pets used in aai as aai are becoming more and more popular in hospital settings the active involvement of veterinarians could play a vital role in working alongside hospital administrative and clinical staff and the aai handlers in developing safeguards to minimize risk and maximize benefits to venerable humans and protect therapy dog welfare conclusions a successful aai hospital protocol and disease prevention program relies on cancer patients parents therapy animals handlers and staff receiving accurate timely advice and information on risk reduction for zoonoses given the health benefits of aai and the vulnerability of pediatric cancer patients well outlined infection control measures must be included in any hospitalclinic protocol for therapy animals minority children particularly the immunocompromised cancer patients are at increased risk for zoonotic infections so additional safeguards should be considered these safeguards include specific consideration for the most common zoonoses associated with animalassisted therapy dogs screenings and preventive vaccinations should be discussed for the zoonoses associated with dogs with moderate risk of transmission considering their wealth of knowledge and expertise on zoonoses veterinarians should be consulted and included in the teams that develop clinical protocols for animal assisted interventions in any oncologic treatment and care setting author contributions cc and sn contributed equally to all parts of this review all authors have read and agreed to the published version of the manuscript

emerging evidence accumulates regarding the benefits of animalassisted interventions aais in facilitating pediatric cancer treatment and alleviating symptomatology through positive changes in the patients emotional mental and even physical status a major concern expressed by healthcare providers and parents in implementing aais in hospital settings is the transmission of disease from animals to patients immunocompromised children such as pediatric cancer patients are at increased risk for petassociated diseases furthermore existing disparities among the racial and ethnic minority groups of pediatric cancer patients can potentially exacerbate their risk for zoonoses this literature review highlights the most common human infections from therapy animals connections to the race and ethnic background of pediatric oncology patients as well as means of prevention the discussion is limited to dogs which are typically the most commonly used species in hospitalbased animalassisted therapy the aim is to highlight specific preventive measures precautions and recommendations that must be considered in hospitals protocols and best practices particularly given the plethora of benefits provided by aai for pediatric cancer patients staff and families

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introduction citizens seeking effective socialization can hardly ignore such components as entrepreneurial political or civic engagement one of the main criteria for interpersonal interaction is considered to be social intelligence it determines how quickly and effectively a person integrates into society and assumes a role in it accordingly the working hypothesis of this research is that people with advanced social intelligence should have higher ambitions about their place in the civic hierarchy the previous research by the authors proved that the level of si development determines a persons desire for selfdevelopment and willingness to be involved in volunteering therefore identifying the relationship between social intelligence and a persons civic ambitions was a logical continuation of the work already done the connection of social intelligence with personal qualities in particular social thinking reflection social sensitivity empathy and social perception was confirmed by different authors in particular onufrieva l it is proved that si is the basis of the communicative and reflective component of the individuals readiness for charitable activity at the psychological level the gender specificity of the development and manifestation of social intelligence is also a very important aspect of the problem of effective personal socialization in particular in the context of political economic and social awareness the problem of the low level of womens involvement in public administration compared to men is relevant for the whole world based on the goal of this study the main task of the experiment was not only to find a reliable influence of social intelligence on the entrepreneurial political and civic ambitions of people but also to identify genderspecific features for the formation of civic consciousness to accomplish this task we conducted an anonymous survey among people actively involved in political civic or business activities this allowed us to identify the connection between their social intelligence and civic ambitions which is relevant for changes in public policy including strengthening gender equality and involving women in government literature review the phenomenon of si has been attracting the attention of scientists since the early twentieth century there are several versions of who first used the term social intelligence the most common opinion is that the american psychologist edward lee thorndike was a discoverer of this concept in 1920 this researcher defined si as the skill of succeeding in relationships with other people while managing them since his work appeared in the nonscientific publication harpers journal some scholars attribute the authorship of the term social intelligence to another scientist namely harry barnes who introduced this scientific concept in his monograph history and social intelligence published in 1926 there are other versions of the origin of the term social intelligence that attribute the authorship to the american psychologist and philosopher john dewey whose research interests included si in 1909 or to lull herbert galen who used the term in his publication in 1911 baumgartner and vasiľova luptak and orosova sarkova madarasova geckova and katreniakova state that other terms like emotional intelligence practical intelligence social competence etc are used in the same sense as social intelligence another problem is that the definition of social intelligence tends to emphasize different components for example barnes and sternberg concentrate on cognitive components ie especially the ability to understand other people ford and tisak focus more on behavioral components ie the ability to interact successfully with others difficulties in understanding the concept also arise from the accepted multidimensionality of social intelligence kosmitzki and john identified the following components perception of other peoples mental states and moods general ability to get along with others knowledge of social rules understanding and sensitivity to complex social situations use of social techniques to manipulate others accepting the points of view of other people and social adaptation as noted by silvera martinussen and dahl some dimensions of social intelligence are closely related to academic intelligence but others are more related to personality traits such as extraversion in general the twentieth century is characterized by rapid growth of global scientific interest in human cognitivebehavioral features with the aim of educating a harmoniously developed individual as a conscious citizen since then psychologists have tried to develop an effective test of social intelligence the tests by j washington gilford and sullivan and other tests are widely used however these questionnaires have a number of drawbacks in common their effectiveness and versatility are reduced due to the timeconsuming nature of completing them the unclear nature of some questions their ambiguous interpretation difficulty in application and low correlation with other tests due to this the search for more effective and universal ways to assess si continues today one of the most versatile and easytouse tests is the tromsø it was developed by d silvera m martinussen and t dahl in their work they relied on the research of o john and k kosmijetski these scholars proposed three basic components of social intelligence social skills social information processing social awareness norwegian researchers initially formulated 103 questions in the final version their number was reduced to 21 questions these authors believe that the questions they proposed fully reveal the level of an individuals si development they do not complicate the process of answering and further analysis of the results data and methods the survey was conducted among entrepreneurial and civic active residents of the ukrainian cities of poltava and pervomayskyi the total number of respondents was 132 the representatives of political parties and public associations opinion leaders entrepreneurs and public activists were invited to participate in the survey the authors are personally acquainted with each of the survey participants the respondents do have certain civic ambitions and leadership qualities in our experiment we used the tromsø test it consists of 21 questions covering social information processing social skills and social awareness the questions of the tromsø test were presented in a mixed way ie the level of development of social awareness social information processing and social skills was not consistently measured but randomly in addition 10 questions were formulated in a positive context and 11 in a negative context this involved coding them this was done on purpose to eliminate the possibility of biased answers the interpretation of the test results consisted of calculating the scores for each factor and dividing the sum by the total number of items to obtain an average score if the respondents average score exceeded 4 it could be assumed that this person has the ability to correctly assess social situations and phenomena in addition they have developed communication skills for each answer a scale from 1 to 7 was defined where one corresponds to the statement not at all about me and seven corresponds to totally about me i can predict the behavior of other people 3 i know how other people will feel after my actions 6 i understand the feelings of other people 9 i understand the desires of other people 14 i can often figure out what other people want without asking them 17 i can predict how others will react to my behavior i can often tell what others are really saying by their facial expressions and body language source own processing i can easily adapt to different social situations 10 i am quick to adapt to new situations and meet new people 12 it is difficult for me to build relationships with other people 15 it takes me a long time to understand other people well 18 i am good at choosing the right words when talking to new people 20 it is difficult for me to find an interesting topic to talk about source own processing the survey was conducted online using a questionnaire created in a google form the work was carried out in february 2023 the data was interpreted using microsoft excel to establish the correlation between the two variables the spearmans rank correlation method was chosen according to the recommendations published in the works of vf bosniuk where x is social intelligence and y is a political social or entrepreneurial activity i find people unpredictable 16 i often offend others without realizing it i am often surprised by the reactions of others to what i do source own processing the results were interpreted in accordance with the recommendations published in the work by turan for this purpose the cheddock scale was used which defines the following possible options for the strength of the correlation between two variables weak 0103 significant 0305 moderate 0507 high 0709 very high 0910 the questions related to determining the level of civic ambition and entrepreneurial engagement of the respondents were added according to a similar evaluation system do you have any business experience from an employee to a business owner 24 what are your political ambitions from being an active member to becoming a city mayor source own processing results and discussion the study revealed a significant positive impact of si on the level of respondents involvement in political business or social activities in addition all people with developed social intelligence sought selfrealization in the communities to which they belonged among those who were interested in participating in the survey the majority were over 31 years of age the age groups were divided approximately equally into three categories 318 341 and 273 young people aged 18 to 30 made up a total of 68 women were also more active which indicates the positive trends in ukrainian society in terms of creating equal opportunities for different genders in the entrepreneurial and civic sphere their share in the survey was 682 compared to 318 among men it turned out that women and men on average show the same level of social intelligence but there is a difference in the development of its individual components as shown in table 5 the dynamics of the distribution of indicators are quite interesting women have the best developed ability to process social information sp slightly less developed social skills ss and less expressed social awareness sa in contrast men rate social skills highest followed by social information processing both women and men have social awareness behind the other components of social intelligence the difference in the development of sp indicators can be explained by the fact that they depend on empathy more than any other si components thereby approaching emotional intelligence which is better developed among women compared to men research by rahim also points to a close connection between social intelligence and empathy which suggests that some components of si and ei are related to each other table 5 results of the analysis of the influence of social intelligence on entrepreneurial engagement and civic ambitions they can be considered as two overlapping sets in contrast men show better socialization skills and awareness of social relations including political and entrepreneurial issues similar conclusions were made by the authors of a study that used a twolevel hierarchical linear model based on the analysis of the results of the 2009 european elections in everyday life this pattern is expressed in a wider range of acquaintances and a willingness to join various social associations however these results are preliminary and require further research with a larger number of respondents the influence of social intelligence on selfcontrol and gratitude is demonstrated in the study by gulliford this opens up a new aspect of the predicted impact on social engagement and political motivation namely the interest of a citizen in his or her own people and country the analysis of the answers of the total sample of respondents presented in table 6 demonstrated a statistically significant positive correlation between social intelligence and civic and entrepreneurial engagement in particular it is best illustrated by the ability to be socially aware ie to possess the necessary information about the political situation in the city region and country as well as the formed axiological component of the personality in fact the research of the respondents by gender given in tables 7 and8 showed a significant difference between the relationship between sa and entrepreneurial political or civic ambition among women and men in particular social awareness was more strongly correlated with social intelligence for women than for men the men demonstrated a stronger correlation between si and social information processing and social skills in contrast female respondents showed a lower correlation between social skills and political and social ambition like men women showed the most significant positive correlation between the si component of social information processing and the examined features in general the correlation between womens social intelligence and motivation to build a political or public career is significantly higher than that of men which can be explained by historically formed gender stereotypes that are still observed in society especially in developing countries ukraine where the study was conducted is one such country while men traditionally have stronger ambitions to join political and public associations this percentage is much lower among ukrainian women this may be due to both the uneven development of si and the differences in its individual components sp and sa many ukrainian women still position themselves as keepers of the home paying less attention to the political sphere of life which is dominated by men given the fact that the distribution of social roles between the representatives of different genders has changed in modern ukrainian society women and men are beginning to accept new norms and rules of behavior gender equality has both sociocultural and biological explanations as table 5 shows female respondents demonstrated almost the same level of social intelligence as men which confirms their equal chances of building a political career it can be suggested that in the context of promoting gender equality in society the development of womens social intelligence will contribute to their more active involvement in social governance and achieving a balance in governing groups our results are in line with the studied components of social intelligence for example sp is responsible for the quick perception and understanding of major trends in society ss determines the ability to find the necessary information and interpret it correctly sa is aimed at the selfidentification of a person as a representative of hisher nation taking into account different views on the components of si it can be noted that social skills social information processing and social awareness were shown to be effective in the research which was also demonstrated by such scholars as silvera and further studies by goswami liadskyi and sanwal it is important that the selected test questions were quite clear to the respondents and did not require additional explanations they revealed a persons view of the level of development of their own social skills knowledge and abilities since the completed questionnaires contain all possible answers it is likely that the invited respondents answered as honestly as possible the test is completely anonymous which also ensures its reliability the respondents were informed of the importance of this research as it is aimed at strengthening gender equality in our country and improving the social and political situation in ukraine their answers helped to verify the scientific hypothesis the confirmation of which opens up broad prospects for building a democratic society with equal opportunities for different age and gender categories further research is also promising in order to establish relationships between social intelligence and other useful qualities of a citizen such as anticorruption charity etc we believe that further research on social intelligence will enable us to develop effective genderequitable recommendations for the development and management of education in schools colleges and universities not only ukraine but every citizen will benefit from this social awareness and motivation to perform socially important activities have a significant positive impact on success conclusion the study of the impact of si on entrepreneurial political and civic engagement revealed a tendency towards a significant positive relationship between the development of social awareness social information processing skills social skills and the desire of a person to actively participate in the life of their locality region or state this result is fully consistent with the scientific assumption made at the beginning of the study we predicted that citizens with developed social intelligence are more likely to have higher ambitions regarding their place in the social hierarchy as social intelligence is closely related to political and civic engagement its development is certainly useful for the formation of a conscious middle class in society among the recommendations that can be made are the following 1 determination of the pedagogical conditions for the formation of social intelligence at the national level in order to integrate such a curriculum into the educational system 2 active promotion of social intelligence among the adult population including writing thematic books publications on the internet and conducting lectures seminars and training 3 development of organizational and methodological support for the introduction of social intelligence into the system of political education of citizens in social assistance centers and organizations that provide assistance in employment developed social intelligence significantly correlates with the willingness of respondents to build an entrepreneurial political or civic career the fact that the authors of the research are personally acquainted with the people who took part in it allowed them to invite only those who are really involved in the local political community or public associations the research showed that entrepreneurial political or civic active women have almost the same level of social intelligence as men which confirms their equal chances of building a career in the public sphere the realization of gender equality largely depends on the level of si of the individual regardless of gender identity thus we can assume that in the context of promoting gender equality in society the development of womens social intelligence will contribute to their more active involvement in social governance and achieving a balance in governing groups the findings suggest the satisfactory psychometric effectiveness of the survey and we will continue to validate it on the slovak population the methodology presented above covers some aspects of the diverse phenomenon of social intelligence this methodology has the advantage of being easy to use and evaluate however it would be more appropriate to combine it with other tools for more comprehensive research the problem of developing new methods that are more focused on the qualitative differences in individual manifestations of social intelligence is still open in this context one possible approach is to apply a situational approach

the research article investigates the relationship between a persons social intelligence according to gender identity and their entrepreneurial and social activity a significant positive impact of the development of social skills social information processing skills and social awareness on a persons motivation to take an active part in the life of their locality region or state interest in politics business or civic activities was identified this result agrees well with the scientific assumption underlying the research that people with developed social intelligence should also have higher ambitions for a place in the social hierarchy choosing business or politics for this purpose the research showed that civically active women have almost the same level of social intelligence as men which confirms their equal chances of building a career

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introduction background and significance of group belongingness group belongingness is a fundamental aspect of human social experience as individuals have an inherent need to belong and form connections with others belonging to a group provides individuals with a sense of identity purpose and support it plays a crucial role in shaping individuals attitudes behaviors and wellbeing understanding the dynamics of group belongingness is important for various domains including psychology sociology organizational behavior and community development definition and conceptualization of social identity and group membership social identity refers to an individuals selfconcept that is derived from their membership in social groups it and emotional attachment to the group group membership on the other hand refers to the formal or informal affiliation of individuals with a specific group or category it involves the identification of oneself as a member of a particular social group such as family cultural occupational or interestbased groups social identity theory proposed by henri tajfel and john turner provides a comprehensive framework for understanding the formation and maintenance of social identity this theory posits that individuals strive to achieve a positive social identity by identifying with and positively evaluating their ingroup while differentiating and negatively evaluating outgroups social identity is the part of an individuals selfconcept that derives from their membership in a social group formation of social identity and group membership social identity theory and its key concepts within social identity theory several key concepts help explain the processes involved in the formation of social identity these concepts include social categorization social identification and social comparison processes involved in the formation of social identity social categorization social categorization is a cognitive process through which individuals classify themselves and others into social groups based on shared characteristics these shared characteristics can include demographic factors such as age gender ethnicity or occupation by categorizing individuals into groups people simplify their understanding of the social world create distinct boundaries between groups and perceive themselves as belonging to specific social categories social categorization provides a foundation for the formation of social identity social identification social identification is the psychological process through which individuals internalize the identity and values of a particular social group it involves adopting the norms values and behaviors of the group as part of ones selfconcept when individuals identify strongly with a group their selfesteem and wellbeing become intertwined with the groups identity social identification provides a sense of belongingness a shared sense of purpose and a source of social support social comparison social comparison is the process of evaluating oneself or ones group in relation to other individuals or groups individuals engage in social comparison to gain information about their abilities opinions and achievements and to develop a sense of selfworth in the context of social identity formation social comparison contributes to the formation of positive distinctiveness positive distinctiveness refers to the desire to perceive ones ingroup as superior to relevant outgroups by emphasizing the positive qualities and achievements of the ingroup and devaluing the outgroup individuals enhance their social identity and selfesteem factors influencing the formation of social identity personal characteristics personal characteristics play a significant role in the formation of social identity personality traits such as extraversion agreeableness and openness to new experiences can influence an individuals inclination to seek out group membership and identify strongly with their ingroup additionally selfesteem and selfconcept clarity play a role in social identity formation individuals with high selfesteem and a clear sense of self are more likely to identify with and derive their social identity from their ingroup group characteristics group characteristics also influence the formation of social identity factors such as group size cohesion and perceived similarity among group members shape individuals social identity larger groups may provide a greater sense of belongingness and social support due to the increased number of potential interactions and shared experiences cohesive groups characterized by strong interpersonal bonds and a shared sense of identity can foster a stronger group identity perceived similarity among group members including shared values attitudes and goals contributes to a sense of collective identity social context and environment the social context and environment play a crucial role in shaping social identity cultural norms societal expectations and historical events influence the formation of social identity socialization practices within a culture or community transmit values beliefs and behaviors that shape individuals identification with specific social groups exposure to diverse cultures and experiences can broaden individuals social identities as they adopt aspects of different groups experiences of discrimination or marginalization based on certain social identities can also heighten individuals identification with their ingroup as a means of coping with discrimination or seeking social support understanding the processes involved in the formation of social identity and the factors that influence it provides valuable insights into human behavior group dynamics and intergroup relations by studying social identity formation researchers can gain a deeper understanding of how individuals come to identify with specific groups and how these identities shape their attitudes behaviors and interactions with others such knowledge has implications for fields such as social psychology organizational behavior intergroup relations and community development maintenance of social identity and group membership importance of maintaining social identity and group membership maintaining social identity and group membership is crucial for individuals wellbeing sense of belongingness and overall psychological functioning belonging to a group provides individuals with a source of support validation and social integration it offers a sense of identity purpose and meaning and can contribute to individuals selfesteem and psychological resilience processes and strategies for maintaining social identity ingroup bias and favoritism ingroup bias refers to the tendency to favor ones own group over outgroups it serves as a mechanism for maintaining social identity by reinforcing positive evaluations of the ingroup and protecting the groups distinctiveness ingroup favoritism involves allocating more resources support and positive treatment to fellow ingroup members social support and cohesion social support from group members plays a vital role in maintaining social identity and group membership supportive relationships within the group provide emotional instrumental and informational assistance fostering a sense of belongingness and solidarity group cohesion characterized by mutual trust cooperation and shared goals enhances the maintenance of social identity identity management identity management involves the strategies individuals employ to maintain a positive social identity this can include engaging in behaviors that reinforce the positive characteristics of the ingroup emphasizing similarities with other group members and distancing oneself from negative stereotypes or stigmatized attributes associated with the group challenges and barriers to maintaining social identity intergroup conflict and prejudice intergroup conflict prejudice and discrimination pose significant challenges to maintaining social identity negative intergroup attitudes and behaviors can threaten individuals identification with their group leading to negative emotional experiences reduced wellbeing and a weakened sense of belongingness social comparison and identity threat social comparison with other groups can create identity threats when the ingroup is perceived as inferior or disadvantaged this can result in negative evaluations of ones social identity and a diminished sense of belongingness social comparison processes that highlight discrepancies between the ingroup and outgroups can undermine the maintenance of social identity changes in group dynamics and composition changes in group dynamics such as leadership transitions membership turnover or shifts in group goals can impact the maintenance of social identity individuals may experience uncertainty conflict or reduced cohesiveness when the group undergoes significant changes posing challenges to their continued identification with the group personality traits play a crucial role in influencing individuals inclination to identify with and form strong social identities for example individuals high in extraversion tend to be sociable outgoing and seek social interactions these individuals may be more likely to actively participate in group activities form connections with group members and develop a stronger sense of group membership agreeableness characterized by warmth empathy and cooperativeness may also contribute to individuals tendency to value and maintain group memberships openness to experience which reflects a willingness to explore new ideas and perspectives may foster a broader range of group memberships as individuals seek diverse social experiences influencing factors of social identity and group membership motivations and needs motivations and needs play a significant role in shaping social identity and group membership the need for affiliation and belongingness as proposed by maslows hierarchy of needs drives individuals to seek social connections and form group memberships individuals with a high need for affiliation may actively engage in group activities seek social support and maintain strong group ties the need for selfesteem also influences social identity as individuals may derive a sense of selfworth and validation from their group memberships group memberships can fulfill individuals needs for recognition status and a positive social identity social categorization is a cognitive mechanism through which individuals classify themselves and others into social groups based on shared characteristics this process simplifies social complexity helps individuals define their social identities and facilitates the identification with specific groups selfperception theory suggests that individuals infer their attitudes and beliefs by observing their own behavior and the context in which it occurs through selfperception processes individuals come to identify with the behaviors and values associated with their ingroup further solidifying their social identity selfconcept clarity which refers to the extent to which individuals have a clear and welldefined understanding of themselves can influence the strength and stability of social identities individuals with higher selfconcept clarity may have a stronger sense of who they are leading to more consistent and committed group identifications group factors group norms and values group norms and values provide a framework for behavior and significantly influence social identity and group membership when individuals align their beliefs attitudes and behaviors with the norms and values of their group it strengthens their identification with the group group norms define appropriate behavior within the group while values represent the core principles and ideals that guide the groups functioning the alignment with group norms and values fosters a sense of belongingness shared purpose and collective identity leadership and group dynamics leadership styles group dynamics and interpersonal relationships within the group contribute to social identity and group membership effective leadership that fosters inclusivity trust and a sense of shared purpose can enhance individuals identification with the group leaders who exhibit transformational leadership qualities such as charisma inspiration and the ability to articulate a compelling vision can facilitate a strong and positive group identity moreover group dynamics such as cohesion cooperation and positive intergroup relations can enhance individuals commitment to the group and strengthen their social identity socialization and role identity socialization processes within a group play a significant role in shaping individuals social identity through socialization individuals learn and internalize the values behaviors and expectations of the group socialization can occur through various means such as direct teaching observation and reinforcement of group norms and behaviors role identity which refers to the set of behaviors rights and obligations associated with a particular position or status within the group contributes to individuals identification with the group individuals develop a sense of belongingness and purpose by fulfilling their roles and responsibilities within the group societal and cultural factors cultural norms and values cultural norms and values significantly influence social identity and group membership cultural expectations and practices shape individuals identification with certain social groups and the importance placed on group memberships within a specific cultural context for example collectivist cultures emphasize the significance of group memberships and promote interdependence cooperation and loyalty to the ingroup in contrast individualistic cultures prioritize individual goals autonomy and selfexpression these cultural variations shape individuals motivations preferences and behaviors related to social identity and group membership social institutions and structures social institutions such as family education systems and workplaces play a crucial role in shaping social identity and group membership these institutions provide socialization mechanisms prescribe norms and values and offer opportunities for individuals to form group affiliations family as the primary socializing agent introduces individuals to their first social groups and influences their early identification processes educational institutions and workplaces often foster group memberships through shared goals collaborative projects and social interactions the norms roles and opportunities provided by these social institutions shape individuals identification with certain groups and the significance of group memberships in their lives media and technology media and technology exert a profound influence on social identity and group membership media representations of social groups can shape individuals perceptions attitudes and identification with these groups the portrayal of certain groups in the media can reinforce stereotypes influence social categorization processes and impact individuals desire to affiliate with or distance themselves from these groups additionally online communities and social media platforms offer opportunities for individuals to connect with likeminded individuals form virtual communities and develop group memberships online platforms provide spaces for individuals to express their identities seek social support and engage in collective action the accessibility and reach of media and technology contribute to the dynamics of social identity formation and group membership by understanding the influencing factors of social identity and group membership researchers practitioners and policymakers can develop interventions strategies and policies that promote positive social identities inclusivity and intergroup harmony this knowledge has implications for various fields including social psychology organizational behavior intergroup relations and community development it can inform efforts to create inclusive environments reduce intergroup conflicts and foster a sense of belongingness and social cohesion methods for investigating social identity and group membership quantitative research methods surveys and questionnaires surveys and questionnaires are commonly used to assess individuals social identity group membership and related variables these selfreport measures provide quantitative data that can be analyzed to understand the factors influencing social identity and group membership experimental designs experimental designs allow researchers to manipulate variables and examine their impact on social identity and group membership through controlled experiments researchers can establish causeandeffect relationships and identify causal mechanisms underlying the formation and maintenance of social identity social network analysis social network analysis explores the patterns of relationships and interactions among individuals within a group or community by mapping social networks researchers can analyze the structure and dynamics of group memberships and how they relate to social identity qualitative research methods interviews and focus groups indepth interviews and focus groups enable researchers to explore individuals experiences perspectives and narratives related to social identity and group membership these qualitative methods provide rich and nuanced insights into the subjective experiences and meaningmaking processes of individuals ethnography and participant observation ethnography involves immersing oneself in a specific social group or community to observe and document their behaviors interactions and cultural practices participant observation allows researchers to gain an insiders perspective and understand the complexities of social identity and group membership within the context of everyday life content analysis content analysis involves systematically analyzing written verbal or visual materials to uncover themes patterns and discourses related to social identity and group membership it can be used to examine media representations organizational documents or online discussions to understand the discursive construction and portrayal of social groups mixed methods approaches mixed methods approaches involve integrating quantitative and qualitative methods to gain a comprehensive understanding of social identity and group membership by combining multiple data sources and research techniques researchers can triangulate findings explore complex phenomena and capture the diversity of experiences and perspectives additionally there is a need for research that examines the intersectionality of social identities and how multiple group memberships influence individuals experiences and sense of belongingness exploring the complexities of overlapping social identities such as race gender and socioeconomic status can provide a more nuanced understanding of social identity and group membership implications and applications practical implications for organizations and communities conclusion summary of the main points discussed in this paper we have explored the formation maintenance and influencing factors of social identity and group membership we discussed the theoretical foundations of social identity theory and the processes involved in the formation of social identity we examined various factors that influence the formation of social identity including personal characteristics group characteristics and the social context furthermore we discussed the importance of maintaining social identity and the strategies and challenges associated with it we analyzed the influencing factors of social identity and group membership including individual factors group factors and societal and cultural factors we explored different research methods for investigating social identity and group membership including quantitative qualitative and mixed methods approaches finally we discussed the implications and applications of understanding and fostering group belongingness intervention strategies for promoting positive group belongingness and future research directions importance of understanding and fostering group belongingness understanding and fostering group belongingness is essential for individuals wellbeing social integration and psychological development group memberships provide individuals with a sense of identity purpose and support contributing to their overall life satisfaction and mental health by understanding the dynamics of social identity and group membership we can create inclusive environments that promote positive group identities and facilitate social cohesion potential impact of social identity and group membership on individuals and society social identity and group membership have a profound impact on individuals attitudes behaviors and wellbeing they influence individuals selfconcept values and beliefs shaping their interactions with others and their engagement in collective actions at the societal level social identity and group membership contribute to the formation of social norms cohesion and collective identity they influence intergroup relations cooperation and conflict therefore understanding and fostering positive group belongingness can have farreaching implications for individuals and society as a whole

this paper explores the concept of group belongingness and investigates the formation maintenance and influencing factors of social identity and group membership drawing upon social identity theory the paper examines the processes involved in the formation of social identity including social categorization social identification and social comparison it also explores the various factors that influence the formation of social identity such as personal characteristics group characteristics and the social context additionally the paper discusses the importance of maintaining social identity and group membership as well as the challenges and barriers to this maintenance furthermore it examines the individual group and societal factors that influence social identity and group membership the paper also delves into the different research methods used to investigate social identity and group membership including quantitative and qualitative approaches finally the implications and applications of understanding group belongingness are discussed along with future research directions the findings highlight the significance of fostering group belongingness for individuals and society as a whole

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introduction hisab rukyat a profound and historical method in islamic astronomy has played a crucial role in determining the times for worship and other religious activities in muslim communities rooted in astronomical knowledge that has evolved since ancient times hisab rukyat is the practice of moon sighting combined with mathematical calculations to determine the beginning of months in the islamic calendar particularly for establishing significant times like ramadan shawwal and the hajj pilgrimage originating from the rich heritage of islamic science which contributed significantly to medieval astronomy hisab rukyat reflects the integration of religious observance with scientific precision this practice not only showcases the islamic worlds historical engagement with astronomy but also underscores the religions emphasis on the harmony of faith and knowledge historically islamic astronomers made substantial contributions to the field developing sophisticated methods for tracking celestial bodies the practice of hisab rukyat therefore is not just a religious obligation but also a celebration of this scientific legacy it serves as a bridge between the past and the present linking traditional methods with contemporary needs of the muslim community through the ages hisab rukyat has adapted incorporating newer technologies and mathematical models to enhance accuracy today it remains a vital aspect of islamic life underpinning the communal rhythm of worship and festivity its relevance extends beyond mere timekeeping symbolizing a unique fusion of faith culture and science as such hisab rukyat stands as a testament to the enduring relationship between the islamic faith and the pursuit of knowledge a relationship that continues to evolve and adapt in the modern world the influence of information technology on modern society has been profound and transformative reshaping various aspects of daily life including religious practices and cultural traditions it has revolutionized communication making it more instantaneous and global thereby bridging geographical and cultural divides this technological advancement has not only altered the way people interact but also how they access and disseminate information in the context of religious practices it has facilitated new forms of worship and community building online platforms and social media have become instrumental in connecting believers disseminating religious teachings and even broadcasting live religious events making spirituality more accessible than ever this digital evolution has also impacted cultural traditions where traditional practices are now being augmented or preserved through digital means for instance religious texts and historical manuscripts are being digitized ensuring their preservation and wider availability furthermore it has enabled the use of sophisticated software in religious and cultural practices such as in the calculation of prayer times and the direction of qibla in islam integrating traditional practices with modern technology however this integration also raises questions about the balance between maintaining traditional values and embracing technological advancements the speed at which information spreads in the digital age also poses challenges in terms of accuracy and authenticity especially in the context of religious teachings and cultural heritage additionally the digital divide referring to the disparity in access to it between different socioeconomic groups can impact how communities engage with their cultural and religious practices overall the role of it in modern society is a complex interplay of facilitating greater accessibility and connection while also challenging traditional norms and creating new dynamics in the realm of religion and culture the integration of information technology in hisab rukyat marks a significant milestone in blending traditional islamic astronomical practices with modern technological advancements this fusion not only enhances the precision and efficiency of moon sighting and astronomical calculations but also represents a progressive stride in embracing technology within the islamic world the traditional hisab rukyat deeply rooted in islamic jurisprudence and astronomy historically relied on direct lunar observation and complex mathematical calculations performed manually the incorporation of it introduces new dimensions to this practice employing advanced software astronomical algorithms and digital tools to refine and streamline the process this integration reflects a broader trend in the islamic world towards reconciling faith with modern science and technology it demonstrates a willingness to adapt and evolve religious practices to stay relevant and accurate in a rapidly changing world the use of it in hisab rukyat not only aids in determining more precise lunar positions and islamic calendar dates but also facilitates wider accessibility for muslims around the globe to observe important religious events in unison this integration is not without its challenges and debates it raises questions about the balance between traditional methods and technological innovation especially in communities where traditional moon sighting holds significant cultural and religious value while some scholars and communities readily embrace the precision offered by it others caution against overreliance on technology advocating for the preservation of traditional practices that have spiritual and communal significance the integration of it in hisab rukyat also symbolizes the ongoing dialogue within islam about the role of science and technology in religious life it underscores the dynamic nature of islamic jurisprudence and its capacity to engage with and incorporate modern advancements this process is not just a technical integration but also a cultural and religious adaptation reflecting the evolving relationship between faith science and technology in the islamic world the sociological impact of integrating information technology into hisab rukyat extends beyond mere technical efficiency reflecting broader cultural and societal dynamics within muslim communities this integration is not just a merger of tradition and modernity but also a reflection of the evolving identity and practices within these communities sociologically the use of it in religious practices like hisab rukyat highlights the adaptive nature of religious communities in response to technological advancements it signifies a shift in how religious knowledge is disseminated and accessed making it more inclusive and widespread however this transition also brings to the fore generational and ideological divides younger generations more attuned to the digital world may find the integration of it in religious practices more natural and beneficial whereas older generations may view it as a departure from tradition this divergence can lead to debates over the correct way of practicing religion challenging the homogeneity of religious experiences and interpretations within the community the integration of it in hisab rukyat raises questions about the authority and authenticity of religious practices with digital tools the determination of religious timings becomes more centralized potentially shifting the locus of religious authority from local scholars to technological experts or centralized bodies this shift can alter the traditional community structures and power dynamics within the islamic world on the positive side the integration of it opens up opportunities for increased participation and engagement in religious practices especially for those in diaspora or remote areas it also offers an educational platform where the principles of hisab rukyat and islamic astronomy can be more easily explained and understood through digital media and applications this can lead to a greater appreciation and understanding of islamic traditions and their scientific underpinnings reliance on it can also lead to a detachment from the experiential aspects of religious practices where personal observation and communal gatherings hold significant spiritual value balancing the efficiency and reach of technology with the preservation of traditional communal experiences becomes a key challenge in conclusion the integration of it in hisab rukyat is a microcosm of the broader dialogue between tradition and modernity in islam it underscores the need for a nuanced approach that respects traditional values while embracing beneficial technological advancements fostering a community that is both progressive and deeply rooted in its rich heritage the primary objective of this research is to comprehensively analyze the integration of information technology in hisab rukyat and its sociological impact on muslim communities seeking to unravel the complex interplay between modern technology traditional islamic astronomical practices and societal dynamics this study aims to answer pivotal questions how does the integration of it in hisab rukyat reshape religious practices and communal structures within islam what are the implications of this integration for the traditional roles of religious scholars and practitioners in the era of digital technology this investigation is driven by the need to understand the depth of its influence not only on the technical aspects of hisab rukyat but also on the cultural and social fabrics of muslim societies it endeavors to explore whether the integration of it challenges or reinforces traditional islamic practices and beliefs examining the potential generational divides and ideological shifts that might arise from this technological intervention the research is designed to probe how the digitization of hisab rukyat affects the communal participation in and perception of religious practices particularly in terms of accessibility inclusivity and authenticity it also seeks to assess whether the technological transformation in hisab rukyat leads to a broader acceptance of scientific approaches within islamic jurisprudence and practice furthermore the study aims to identify potential challenges and opportunities that emerge from the confluence of technology and tradition especially in maintaining the balance between efficiency and spiritual essence by addressing these questions the research aims to provide insightful perspectives on the evolving relationship between religion technology and society offering a nuanced understanding of how technological advancements are negotiated within the framework of islamic traditions and practices in the literature review section of our article we delve into the intersection of hisab rukyat it integration in islamic practices and the sociological impact of technology on muslim communities anchored by several scholarly references the historical and practical dimensions of hisab rukyat are insightfully explored in works like the study in alhilal journal of islamic astronomy which discusses the astronomical interpretation of early prayer times underlining its significance in islamic practices the nuanced role of it within islamic traditions is further illuminated in the paper integrating islamic traditions in modern psychology from semantic scholar revealing the adaptation of modern technological tools within islamic frameworks concerning the sociological implications of it the impact of information technology on muslim society from researchgate provides a comprehensive examination of how technology influences societal structures and practices in muslim communities complementing this perspective is the article muslim scholars and technological volition from sciencedirect which discusses the valueladen nature of technologies and their influence on actions and goals within the muslim context lastly the proceedings from the project muse impact of emerging digital technology and social media on muslim communities conference offer a detailed analysis of the reshaping of muslim communities through digital technologies and social media these varied sources collectively provide a multifaceted view of the integration of it in hisab rukyat and its broader implications highlighting a landscape where tradition intersects with modernity leading to a complex array of challenges and opportunities in the islamic world b method in this study we adopted a qualitative approach to deeply understand the impact of information technology integration in hisab rukyat and its implications for muslim communities the focus was on urban and semiurban muslim communities with participants selected through purposive sampling to capture diverse perspectives primary data were gathered through indepth interviews with mosque imams islamic astronomy experts and community members supplemented by participatory observations at various locations we also incorporated document analysis including religious texts and online materials related to hisab rukyat data collection tools such as questionnaires and interview guides were developed based on literature review and validated by experts in islamic studies and the sociology of technology the research process spanning six months involved initial preparation field data collection and intensive analysis thematic analysis was applied to process data from interviews allowing for the identification and interpretation of key themes related to the use of it in hisab rukyat ethical aspects of the research were strictly observed including obtaining informed consent from all participants ensuring anonymity and safeguarding sensitive data we acknowledge limitations in our methodology including the relatively small sample size and limited geographical focus which may affect the generalizability of the research findings however we endeavored to mitigate these limitations through indepth data analysis and source triangulation to enhance the reliability and validity of our findings this methodology was designed to capture the complexity of interactions between it hisab rukyat and social dynamics in diverse contexts providing valuable insights into how religious traditions adapt to modern technological advancements c results and discussion the research unearthed a significant variation in the acceptance of it integration within hisab rukyat across muslim communities revealing a generational divide in attitudes towards technology in religious practices younger muslims displayed a greater openness to incorporating it in hisab rukyat viewing it as a means to enhance accuracy and convenience this group often emphasized the benefits of embracing modern technology to keep religious practices aligned with contemporary life in contrast older generations tended to hold a preference for traditional methods expressing concerns that overreliance on technology might lead to a loss of spiritual essence in religious observances their apprehension was rooted in the belief that traditional methods such as direct moon sighting carried not just astronomical but also significant spiritual and communal value the study found that this divergence in views often led to lively debates within communities about maintaining tradition versus embracing modernity it was observed that while younger members were techsavvy and comfortable with digital tools older members valued the communal aspect and the experiential nature of traditional practices this generational gap pointed to a broader theme of how religious communities navigate changes brought by technological advancements the research also highlighted a need for dialogue within communities to reconcile these differing views and find a middle ground that respects tradition while leveraging the benefits of technology furthermore it underscored the importance of educational initiatives to familiarize older generations with the advantages and potential uses of it in hisab rukyat the findings suggested that such initiatives could help bridge the gap fostering a more inclusive approach to technology adoption in religious practices overall the study illuminated the dynamic nature of religious practice in the digital age showcasing how communities adapt negotiate and sometimes resist technological changes in the realm of religious observance the second key finding of the study illustrates that the integration of information technology in hisab rukyat serves not only as a tool for preserving traditional methods through digitalization but also as a catalyst for innovation within islamic astronomical practices this dual role of it emerged as a significant theme in the research the digital preservation of hisab rukyat methods ensures the longevity and accessibility of these practices allowing for a wider reach among muslims globally irrespective of their geographical location the study found that digital platforms and applications enable the dissemination of hisab rukyat knowledge promoting a deeper understanding and appreciation of this traditional practice among younger generations who are more technologyoriented on the innovation front the research revealed that the integration of it brought about advancements in the accuracy of lunar observations and calculations sophisticated software and astronomical tools have enhanced the precision of moon sighting which is crucial for determining important islamic dates and rituals this technological advancement was welcomed by many participants who saw it as an improvement in the reliability of religious observance alongside these positive aspects some concerns were raised about overreliance on technology potentially leading to a detachment from the handson experience and skills traditionally associated with hisab rukyat this concern was particularly voiced by practitioners who have long relied on direct observation methods the study also highlighted a growing interest in developing hybrid models that combine traditional sighting methods with technological tools aiming to balance authenticity with accuracy respondents expressed that innovation through it should respect the underlying principles and values of hisab rukyat ensuring that technological enhancements do not overshadow the spiritual and cultural significance of this practice the research thus underscored the nuanced and careful approach needed in integrating it into religious practices ensuring that technology serves as a complement rather than a replacement for traditional methods these findings provide insights into how religious traditions can evolve and adapt in the age of technology striking a balance between preservation and innovation the third major finding of this research revolves around the shift in power dynamics and religious authority stemming from the integration of information technology in hisab rukyat this technological infusion has led to a notable centralization of authority in determining religious timings which historically were more decentralized and locally driven traditionally local religious scholars and observatories held the responsibility for moon sighting and declaring important islamic dates fostering a sense of community and shared participation however the study found that with the advent of it these decisions are increasingly being influenced by centralized religious bodies or technological experts this shift raises important questions about the role and influence of local religious authorities versus centralized institutions in the digital age participants expressed concerns that this could lead to a reduction in community engagement and a sense of disconnection from the process the research also revealed apprehensions about the potential loss of regional diversity in islamic practices as technology tends to standardize methods and interpretations on the other hand some participants viewed this centralization as a positive development arguing that it leads to greater consistency and unity in religious observance across different regions the findings also pointed to a growing need for religious scholars to be wellversed in both traditional islamic jurisprudence and modern technology to effectively bridge the gap between the two realms this emerging scenario underscores a complex negotiation between maintaining traditional religious structures and embracing technological advancements the study highlights the critical need for thoughtful deliberation within the muslim community to navigate these changes ensuring that the essence of religious practice is preserved while also embracing the benefits of modern technology these dynamics reflect the broader challenges faced by religious communities in adapting to rapid technological changes while maintaining their core beliefs and practices the fourth significant finding from the study highlights the profound impact of information technology on communal life and participation in religious activities within muslim communities the research revealed that it particularly in the context of hisab rukyat has transformed the ways in which muslim communities interact and engage with religious practices on one hand the accessibility and convenience offered by it have led to increased inclusivity allowing wider segments of the muslim population including those in remote or diaspora communities to participate in religious observances more easily digital platforms and apps have made information about prayer times and religious dates readily available enhancing the ability of individuals to observe religious rituals in sync with the global muslim community this technological facilitation also brings with it certain challenges the study found that the reliance on digital tools for religious observance could potentially decrease physical participation in communal activities such as group prayers and moon sighting events this decline in physical participation could lead to a weakening of communal bonds and a sense of disconnect from the traditional communal experience of religious practices the findings also indicated that while technology facilitates individual access to religious information it may inadvertently reduce opportunities for communal learning and interaction which have been integral to the transmission of religious knowledge and the fostering of community spirit in islam the research underscored the importance of maintaining a balance between leveraging the benefits of it and preserving the rich tradition of communal engagement in islam the findings suggest that while technology can enhance the practice of hisab rukyat and other religious observances it should be used in a way that complements rather than replaces the traditional communal aspects of these practices the study calls for a thoughtful approach to the integration of technology in religious life one that preserves the essence of communal worship and learning while embracing the advantages of modern digital tools this balance is crucial for sustaining the vibrancy and cohesiveness of muslim communities in the digital age the fifth and a pivotal finding of this research focuses on the ethical and moral considerations emerging from the integration of information technology in hisab rukyat the study brought to light various ethical dilemmas and moral questions that arise when traditional religious practices intersect with modern technology one of the primary concerns raised was the potential loss of spiritual and communal elements inherent in traditional practices like direct moon sighting participants expressed apprehension that the emphasis on technological precision might overshadow the intrinsic spiritual experience associated with observing and participating in religious rituals this concern highlighted a broader debate about the role and impact of technology in religious life and the importance of preserving the essence of spiritual experiences in the digital age the research identified a growing need for ethical guidelines and frameworks to navigate the integration of it in religious practices such guidelines would address issues like data privacy the security of digital platforms used for religious observance and the ethical use of technology in religious contexts the study also revealed concerns about the commodification of religious practices where technology could potentially commercialize aspects of religious observance thus moving away from their original spiritual intent the findings emphasized the importance of community involvement in decisionmaking processes related to the integration of it in religious practices this involvement ensures that the adoption of technology aligns with the values and beliefs of the community and is not merely driven by technological advancement the research suggested that open dialogues and discussions within the community could facilitate a more ethically grounded approach to incorporating it in religious practices the study concluded that while technology offers numerous benefits in terms of efficiency and accessibility its integration into religious practices like hisab rukyat requires careful consideration of ethical and moral aspects it calls for a balanced approach that respects the spiritual moral and communal dimensions of religious observance ensuring that technology serves to enhance not diminish the religious experience this balance is essential for ensuring that the integration of it in religious practices is both meaningful and respectful of the rich traditions and values of the muslim community the first finding of this study highlights a variance in technology acceptance across different generations within muslim communities aligning with the research by hameed badii and cullen which emphasizes how generational differences impact technology adoption the younger generation raised in the digital era tends to be more open to integrating it into religious practices a phenomenon explained by eickelman and anderson as part of the globalization process within muslim communities in contrast the older generation often exhibits resistance to technological change as highlighted by raja who emphasizes the importance of traditional values and direct experience in religious practices this gap creates an intriguing dynamic where technology becomes a contested field between modernity and tradition as revealed in bunts study on islam in the digital age this research also echoes bunts findings indicating that digital technology can be a crucial tool in facilitating religious practices but also raises questions about authenticity and interpretation thus this study provides significant insights into how muslim communities navigate the changing technological landscape in line with warschauers suggestion that technology is not just a tool but also a field where social values and norms are contested and negotiated analyzing the second finding on preservation and innovation in it integration within hisab rukyat the study discovers that digital technologies not only aid in preserving traditional islamic astronomical practices but also foster innovation this dual role aligns with the assertions of bunt who discusses the transformative impact of digital technologies in religious contexts the research highlights that digitalization ensures the longevity and wider accessibility of hisab rukyat resonating with the findings of eickelman and anderson who emphasize the role of new media in expanding the public sphere in the muslim world the innovative aspect as revealed in the study aligns with warschauers viewpoint on the role of technology in societal transformation the integration of it has led to advancements in the accuracy and reliability of lunar observations echoing hameed badii and cullens observations on technology enhancing traditional practices however the study also brings to light concerns about maintaining the balance between innovation and the essence of tradition a concern similar to what raja identified in the context of preserving cultural authenticity amidst technological advancement this finding suggests that while technology can significantly enhance the practice of hisab rukyat it is crucial to navigate its integration carefully to maintain the spiritual and cultural significance of these practices as highlighted by bunt in his study on digital religious environments thus this research contributes to the understanding of how technological advancements can be harmoniously integrated into religious practices ensuring that innovation complements rather than supplants traditional methods in analyzing the third finding regarding the dynamics of power and authority in the integration of information technology in hisab rukyat the study underscores a shift towards centralization of religious authority this transition as highlighted by bunt reflects a broader trend in the digital age where religious practices and authority are being reconfigured the research aligns with eickelman and andersons observations on how new media technologies are reshaping religious authority and community dynamics the traditional decentralized model where local religious leaders played a key role in hisab rukyat is being challenged by the emergence of centralized itdriven models echoing warschauers discussion on how technology can alter power structures this centralization of authority in determining religious timings as found in the study resonates with hameed badii and cullens findings on the impact of technology on traditional practices the study reveals concerns about the potential diminishment of local religious authority and diversity a concern also noted by raja in the context of maintaining cultural and religious diversity in the face of globalization and technological change the research highlights the need for a balanced approach in integrating it into religious practices ensuring that the essence of communitybased decisionmaking is not lost as emphasized by bunt in his analysis of cyberislamic environments the findings suggest that while technology can provide a unified approach to religious observance it is crucial to consider the implications on local religious authority and community engagement this analysis contributes to the understanding of the complex interplay between technology religious authority and community dynamics in the modern muslim world the fourth finding focusing on the impact on communal life reveals how information technology is reshaping interaction and participation in religious activities within muslim communities this finding aligns with warschauers discussion on the digital divide reflecting how access to technology can both include and exclude segments of the community the study echoes eickelman and andersons observations on the role of new media in redefining public spheres in the muslim world facilitating increased access and inclusivity in religious observance however it also highlights the potential decline in physical participation and social interaction a concern resonant with bunts analysis of digital religion where the physical and communal aspects of religious practices might be overshadowed by digital engagements the research underscores a complex dynamic where technology while enhancing access to religious information and observances could potentially diminish the traditional communal and social interactions that have been central to the muslim community as noted by raja in the context of cultural and religious practices this shift as found in the study suggests a transformation in the way religious learning and communal bonds are forged echoing hameed badii and cullens findings on the impact of technology on learning environments the study emphasizes the need for a balanced approach to integrating technology in religious life ensuring that the benefits of increased access and inclusivity do not come at the expense of communal participation and interaction this balance is crucial in maintaining the essence of communal worship and learning while embracing the advantages of modern digital tools a perspective supported by bunts exploration of cyber islamic environments this analysis contributes to the broader discourse on how technology is transforming religious practices and community dynamics in the muslim world the fifth finding addressing ethical and moral considerations in the integration of information technology in hisab rukyat underscores the emerging ethical dilemmas and moral questions in this intersection of technology and religious practice this aligns with warschauers discussion on the societal implications of technology highlighting how its integration can raise ethical concerns the study reflects on the apprehensions about the potential loss of spiritual and communal elements echoing bunts exploration of the impact of digital environments on religious experiences where there is a risk of spiritual practices becoming overly reliant on technological precision the concerns about the commodification of religious practices as indicated in the study resonate with eickelman and andersons observations on the commercialization of religious content in the digital age the research also suggests a need for ethical guidelines in managing digital platforms for religious observance addressing issues like data privacy and security a concern shared by raja in the context of technologys role in cultural and religious settings the study highlights the importance of community involvement in decisionmaking processes about technology integration in religious practices aligning with hameed badii and cullens findings on the impact of community engagement in blended learning environments this involvement ensures that technological adoption aligns with the values and beliefs of the community bunts analysis of imuslims further supports the idea of having open dialogues within communities to navigate these ethical concerns this analysis contributes to the understanding of the complex ethical landscape emerging from the fusion of technology and traditional religious practices it underscores the need for a balanced approach that respects spiritual moral and communal dimensions ensuring that technology enhances rather than detracts from religious experiences d conclusion the study digital transformation in hisab rukyat a sociological perspective on integrating information technology in islamic astronomical tradition concludes that the integration of information technology in hisab rukyat is a multifaceted phenomenon with significant implications for muslim communities it reveals a generational divide in the acceptance of technology where younger members are more receptive to the integration of it in religious practices while older generations often prefer traditional methods this generational gap underscores the need for a balanced approach that respects both tradition and modernity the study also highlights the dual role of it in preserving traditional hisab rukyat methods through digitalization and inspiring innovation in islamic astronomical practices however it raises concerns about maintaining the balance between innovation and the preservation of traditional values the shift in power dynamics and religious authority towards centralization as a result of it integration poses challenges to the traditional decentralized and locally driven approach in islamic communities this centralization risks diminishing the role of local religious authorities and potentially reducing community engagement in religious practices conversely it also offers a unified approach to religious observance which can enhance consistency across different regions the impact of technology on communal life is significant enhancing access and inclusivity in religious observance but potentially diminishing physical participation and communal bonds this shift necessitates a thoughtful approach to technology integration ensuring that it complements rather than replaces communal religious experiences the study also brings to light various ethical and moral considerations such as the potential loss of spiritual essence in religious practices and the need for ethical guidelines in managing digital platforms in conclusion while it offers numerous benefits in terms of efficiency and accessibility its integration into religious practices requires careful consideration of its impacts on tradition community dynamics and ethical standards this study contributes to the understanding of how religious traditions can evolve and adapt in the age of technology emphasizing the importance of striking a balance between preservation and innovation ensuring that the integration of it in religious practices is meaningful and respectful of the rich traditions and values of the muslim community

this research investigates how the integration of information technology it in the practice of hisab rukyat a traditional method in islamic astronomy for determining prayer times is transforming the social and cultural landscape in muslim communities employing a qualitative approach the study collected data through indepth interviews participatory observations and analysis of documents related to the hisab rukyat bodies in various countries findings indicate that the adoption of it not only enhances accuracy and efficiency in astronomical calculations but also sparks sociological debates over balancing technological innovation with tradition furthermore the study identifies shifts in community dynamics where younger generations are more receptive to technological use while older ones tend to adhere to traditional methods these findings suggest that while it provides a more efficient means for calculations an intergenerational dialogue is also necessary to maintain cultural continuity in this digital transition the implications of this study are significant for policymakers religious communities and academics interested in the interplay between technology society and religious traditions

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introduction colorectal cancer ranks second for all cancer related deaths among men and women together and third for either sex when considered separately in the united states of america 1 previous studies suggest there may be important ruralurban differences e 1 1 6 0 4 1 original articles epidemiology biostatistics and public health 2015 volume 12number 4 colorectal cancer socioeconomic distribution and behavior in colorectal cancer incidence and mortality among men and women in the united states 2 such geographic variation may be partly due to differences in colorectal cancer screening because routine screening can reduce both mortality from the disease and morbidity over time 3 although colorectal cancer screening rates have increased over time increases have been lower in those who are less educated have a lower income lack health insurance and are hispanic 45 analysis of the 1999 and 2008 brfss showed that rural residents were also less likely to receive recommended colorectal cancer screening than their urban counterparts 67 while socioeconomic status may directly predict cancerscreening behavior crc risk is also influenced by several behaviors other than screening regular physical activity provides a protective effect against colorectal cancer whereas obesity is associated with increased risk 8 9 10 vegetarian diets are associated with lower incidence of colorectal cancer 11 equivocal evidence has also been found for a link between dietary fat intake and colorectal cancer risk 1213 there is accumulating evidence linking increased risk for colorectal cancer with high red meat intake 1415 high intake of alcohol 16 and smoking 17 these behavioral risk factors for crc might contribute to observed differences in crc incidence with geographic location several studies have investigated the relationship between rurality and cancer one of the most important findings is that rural residents are generally diagnosed at a later stage and have decreased survival rates as opposed to their urban counterparts 18 the difference in outcomes has been linked to differences in socioeconomic and behavioral factors including cancerscreening behavior 19 secondary prevention by way of screening and early detection and treatment could reduce observed differences in crc outcomes between rural and urban populations in addition to efforts to increase screening rates 20 modification of behavioral risk factors 2122 can significantly reduce crc risk 23 even among individuals who are adherent to colorectal cancer screening 24 the purpose of the present study is to explore any differences in crc incidence and mortality between randomly selected rural and urban counties in the usa the a priori hypothesis was that any observed differences in crc mortality between rural and urban counties would mirror differences in socioeconomic factors and screening behavior furthermore any observed differences in crc incidence between rural and urban counties would be reflected by differences in behavioral risk factors for crc such as smoking and alcohol consumption as well as educational and income levels methods data collection data for the present crosssectional study were collected from the surveillance epidemiology and end results program of the national cancer institute and the behavioral risk factor surveillance system of the centers for disease control and prevention initially colorectal cancer incidence and mortality rates for the year 2011 were calculated for all counties in the seer18 registry database using seer stat version 81525 incidence and mortality rates per 100000 atrisk citizens were generated using the 2000 us census standard population estimates socioeconomic status variables for all counties in the study were also calculated using seer stat specifically we created two socioeconomic variables based on the 2000 us census percentage of the county population with less than a high school education and percentage of the county population living below poverty selfreport data for three crc behavioral risk factors were downloaded from the standardized 2011 brfss telephone survey database which included adults aged ≥18 amount of time since last doctor visit smoking frequency and alcohol consumption since the data from the brfss were available at the individual level and data from the seer program were available at the county level the individual brfss data to match the county seer program data were aggregated permitting a comparison of crc incidencemortality socioeconomic status and behavioral factors to achieve the aforementioned objective the brfss participants by county were grouped and the percentages or averages for the variables listed above were calculated specifically for each county the following behavioral variables e 1 1 6 0 4 2 colorectal cancer socioeconomic distribution and behavior were calculated percentage of the county population that visited the doctor within the last year percentage of the county population that reported smoking every day and the county populations average number of alcoholic drinks consumed per month sample first the counties were classified either as urban or as rural using the data from the 2013 national center for health statistics urbanrural classification scheme for counties 26 second after the individual level data from the brfss survey were aggregated to the county level the county listings in the seer database and the brfss database were compared a comparison of county listings enabled the creation of a database that permitted the pooling of counties held in common by the brfss and seer databases in order to randomly select urban and rural counties from the database a random number generator in excel version 1448 with the function randbetween was used according to cohen 27 a ttest with two groups as in the case of the present study will garner statistical power of 80 percent with a mediumlarge effect size if 30 observations are included in each cell thus a total of 50 urban counties and 50 rural counties were randomly selected from the pool of usa counties with the method previously described as cohens method is only a baseline recommendation procedures in order to answer the research questions in the present study a diversity of descriptive and inferential statistical techniques were applied to the data firstly means and standard deviations were calculated for each variable crc incidence crc mortality percentage of the county population that visited the doctor in the past year percentage of the county population that reported smoking every day alcoholic drinks consumed per month educational levels and poverty in the study at the rural urban and national levels we also calculated mortality to incidence ratios for crc within rural counties within urban counties and within the national sample and the rate ratio for crc incidence and mortality between rural and urban counties 28 secondly a series of independent samples ttests were conducted after removing outliers by standardizing the observations and eliminating observations beyond 329 standard deviations from the mean 29 in order to determine if rural and urban counties differed in the expression of the variables under study to the extent that multiple ttests were performed in the present study we resolved to control the incidence of type i error by applying the bonferroni correction to three families of hypothesis tests while some researchers have suggested that a family of tests should be defined as those which are conducted within the span of a researchers career 30 others have suggested that such an approach is too conservative and leads to the incidence of type ii error therefore it is prudent to define a family of tests a priori as those which are related 3132 on the basis of the discussion herein presented the definition of a family of ttests in the present study followed the ensuing protocol colorectal cancer variables bonferroni corrected α 0025 behavioral variables bonferroni corrected α 00167 and socioeconomic status variables bonferroni corrected α 0025 we also computed cohens effect size d for each comparison which is a measure of practical significance as kirk 33 explained null hypothesis tests and their associated test statistics indicate whether a result is due to sampling variability or perhaps chance however effect sizes by showing how far apart the means of two samples are in terms of standard deviations indicate whether the differences are useful in the real world thirdly ordinary least squares multiple regression models were calculated in order to represent a prediction of how the various behavioral and socioeconomic status variables influenced the presentation of crc incidence and mortality at the rural urban and national level a standard forced entry method utilizing one step was adopted for the analysis as previous research has shown that the variables under study exert significant influence on the expression of crc incidence and mortality confidence intervals were for crc incidence between rural and urban counties with the rural counties serving as the numerator in the equation showed that rural counties were at a higher risk for crc incidence similar results were obtained in the rr analysis of crc mortality between rural and urban counties a greater percentage of the population in rural counties compared to urban counties reported that they had visited the doctor at least once within the last year while cigarettesmoking frequency was higher in rural counties alcohol consumption was higher in urban counties additionally lower levels of education and higher levels of poverty were evident in rural counties three families of bonferroni adjusted ttests were generated in order to answer the research questions regarding cancer outcomes significant differences were found between rural and urban counties specifically the results showed that differences between ruralurban crc incidence rates were practically significant and statistically significant at the bonferroni adjusted alpha level of 025 furthermore differences between ruralurban crc mortality rates were practically significant and statistically significant at the bonferroni adjusted alpha level of 025 the second family of ttests included behavioral factors implicated in the incidence of crc while statistically significant differences were not detected between rural and urban counties in terms of the percentage of the population that had visited the doctor within the last year statistically significant differences were detected for smoking frequency and alcohol consumption specifically the results showed that populations living in rural and urban counties differed in the quantity of cigarettes smoked within the last 30 days practical significance was also discovered for this comparison according to cohens effect size index furthermore differences in alcohol intake were practically significant and statistically significant for rural and urban counties at the bonferroni adjusted alpha level of 0167 in order to determine if rural and urban counties differed on essential socioeconomic variables a third family of ttests was built into predictors of rural crc incidence and mortality in order to determine the extent of influence of behavioral and socioeconomic factors on the incidence and mortality of rural crc unstandardized ols regression models were generated the regression model for rural crc incidence was statistically significant and accounted for 214 percent of the variance in crc incidence monthly smoking frequency emerged as the strongest predictor of crc incidence as well as the only significant predictor in the model the regression model for rural crc mortality which accounted for 146 percent of the variance in mortality also showed statistical significance while alcohol consumption materialized as the only statistically significant predictor in this model smoking frequency and poverty appeared to exert relative influence on rural crc mortality predictors of urban crc incidence and mortality urban crc incidence and mortality predictors were determined using unstandardized ols regression models the results showed that the regression model for urban crc incidence with time since last checkup at the doctor smoking frequency alcohol consumption education and poverty as independent variables was statistically significant overall this model accounted for 337 percent of the variance in the dependent variable urban crc incidence monthly smoking frequency surfaced as the only statistically significant predictor and as the strongest predictor in the model although education presented as a relatively important variable regarding urban crc mortality regression analysis revealed that the socioeconomic and behavioral variables in the study exerted relative influence with smoking frequency as the strongest and only predictor the adjusted r2 value for this model suggested that the independent variables accounted for 245 percent of the variance in urban crc mortality predictors of national crc incidence and mortality the regression models for both national crc incidence and mortality showed a good fit to the data and respectively with monthly smoking frequency presenting as the most influential predictor of both crc incidence and mortality overall this model accounted for 309 percent of the explained variability in crc incidence the adjusted r 2 value for this model suggested that the independent variables accounted for 201 percent of the variance in the dependent variable in looking at the findings of each regression model including the national regression models one independent variable emerged as repeatedly predictive of crc incidence and mortality specifically in all models save the rural crc morality model in which alcohol was the only predictor smoking was not the strongest predictor of crc incidence and mortality but the only statistically significant predictor discussion health disparities have been observed between rural and urban regions around the world several risk factors have been described as potential drivers of this epidemiological polarization 34 access to health care including distance from medical facilities physiciantopopulation ratio availability of cancer detection technologies and screening methods constitute some of the most important aspects of social e 1 1 6 0 4 6 deprivation and rurality 3536 limited financial resources and economic factors tend to augment these disparities even further the availability of public versus private medical centers and public health insurance coverage of medical costs is also detrimental 37 moreover health promotion and education is usually minimal in rural populations limited disease control and prevention is predisposing for increased incidence and mortality from chronic diseases behavioral factors such as smoking diet and alcohol consumption may alter individual outcomes albeit cultural or religious beliefs may be equally important 3839 in the present study possible variations in crc incidence and mortality between rural and urban counties in the usa were explored the possible role of socioeconomic status and behavioral risk factor variations between rural and urban counties that may partly explain any observed differences in crc incidence and mortality between the selected rural and urban counties were also evaluated specifically educational and income levels were selected as two measures of ses since these two directly influence health and healthseeking behavior as well as health outcomes the relative percentages of people without a high school education for the rural and urban counties were used as a measure of ses and the percentage of people living below the poverty line for the rural counties compared to the urban were also assessed previous studies have already cited smoking and alcohol consumption as behavioral risk factors for crc 1617 therefore possible differences between smoking levels and average alcohol consumption between rural and urban counties as partly responsible for any observed differences in crc incidence and mortality between rural and urban counties were explored last visit to the doctor in the past year was used as a proxy of cancer screening behavior and looked at differences between percentages of rural and urban populations who had seen a doctor in the past year to mirror possible differences in crc incidence and mortality due to early diagnosis and relatively favorable outcomes for those screened and diagnosed in the early stages of crc as mentioned in the results and shown in table 1 significant differences exist for crc incidence and mortality between rural and urban counties both being higher in rural counties compared to urban the mortalityincidence ratio of crc for randomly selected rural counties stood at 03441 compared to 03146 for randomly selected urban counties this means that 3441 percent of all crc cases in rural counties will have fatal outcomes compared to 3146 percent of all crc cases in urban counties some studies have used mir as a proxy for 5years survival rate and as an indicator for sex and racial disparities in cancer survival 40 the difference in outcomes showed in the present investigation can be attributed to differences in socioeconomic factors crc screening behavior which by itself may be influenced by ses factors including health insurance status as well as availability of health resources the result of these interrelated factors will be the diagnosis of relatively more cases of crc in advanced stages of the disease in rural settings compared to those in urban areas where relatively higher ses levels coupled with better health resources and crc screening behavior lead to early diagnosis and relatively more favorable outcomes as suggested by the mir of crc for urban counties compared to rural counties since the results showed practically and statistically significant differences in the two important ses variables used for the analysis educational level and poverty as shown in table 1 it may be reasonable to say that these differences may partly explain the observed differences in crc incidence and mortality between the selected rural and urban counties especially when the means for educational level and income are compared between the two there are more people living below the poverty line in the rural as compared to the urban counties and similarly there are more people with less than a high school education in the rural compared to urban counties as shown in table 1 which together means the socioeconomic conditions using education and income place the urban counties above the rural by extension therefore since educational level is a predictor of income and combined the two influence health and healthseeking behavior it stands to reason that differences in crc incidence and mortality may partly be accounted for by the differences in educational and income levels between the rural and urban counties with regard to behavioral risk factors the results showed that there was no statistical significance in our proxy for cancer screening behavior last visit to the doctor nonetheless previous studies have reported differences in cancer screening behavior between rural and urban populations as a contributor to observed disparities in crc incidence and mortality between rural and urban counties 1718 since last visit to doctor was used as a proxy to crc screening behavior it is likely the practical and statistical insignificance of same with regard to differences between rural and urban counties may be due to the selected variable not being a good proxy for cancer screening behavior and so not reflecting differences that may exist between rural and urban counties in actual crc screening behavior as far as smoking is concerned the results indicate that the percentage of people who smoke every day is higher for the rural counties than it is for the urban counties the differences so observed proved practically and statistically significant as shown in table 1 since smoking as indicated previously is a behavioral risk factor for crc again it stands to reason that the relatively higher smoking indulgence in the rural compared to urban counties may partly contribute to the observed higher incidence and mortality for crc in rural counties compared to the urban counties alcohol consumption has been suggested as a behavioral risk factor for crc however some studies suggest that the risk posed by alcohol for crc is dosedependent there is strong evidence for an association between alcohol drinking of 1 drinkday and colorectal cancer risk 41 a metaanalysis of 57 cohort and casecontrol studies that examined the association between alcohol consumption and colorectal cancer risk showed that people who regularly drank 50 or more grams of alcohol per day had 15 times the risk of developing colorectal cancer as nondrinkers or occasional drinkers 42 from the results in table 1 it is clear that alcohol consumption is higher in the urban counties compared to the rural despite this difference in alcohol consumption being practically and statistically significant alcohol consumption by itself does not seem to contribute to the risk of crc for either rural or urban populations since the weighted average consumption per person is far less than the suggested threshold of 1 unit per day for any risk of crc to be realized for both rural and urban populations giving that the weighted averages of alcohol consumption for either population were used rather than individual variations in alcohol consumption the results so observed might be different if individual units of alcohol consumed per month were used in the analysis for specific cases of crc and related outcomes for same the next phase of our analysis sought to examine the extent to which ses and behavioral factors influence crc incidence and mortality for rural urban and national populations using unstandardized regression models monthly smoking frequency emerged as the only significant predictor of crc incidence for both rural and urban counties as well as the national pool with alcohol consumption educational and income levels variously influencing crc mortality across board as mentioned earlier in the results and shown in table 2 our results highlight the risk of smoking behavior on crc incidence and mortality among rural and urban counties in the usa public health education programs and social marketing campaigns should emphasize the role of monthly smoking frequency on the manifestation of crc especially in rural counties as smoking frequency is higher in rural counties than urban counties in the usa this paper has various strengths such as the coupling of data from the brfss and seer the identification and confirmation of existing differences in crc incidence and mortality between rural and urban counties and the possible role of behavioral and ses factors in these observed differences despite these strengths some weaknesses of this research paper have been observed the paper used county level data making analysis on weighted means and aggregates without recourse to individual variations in behavior and crc incidence and outcomes across counties rural and urban we also consider the wide variations in geographic and population size a limitation to this paper conclusion multiple ses and behavioral factors variously and independently influence the incidence and outcomes of crc in the usa without adequately addressing these palpable variations in ses and behavioral factors between rural and urban populations in the usa the disparities in crc incidence and mortality between rural and urban populations will likely get worse health policies aimed at reducing disparities between rural and urban populations in the usa must therefore adequately address ses and behavioral factors we recommend further research with larger sample sizes and more ses and behavioral factors to see the full dimension and impact these factors may have on crc incidence and mortality in the usa to better inform policies meant at bridging these disparities

background colorectal cancer crc ranks second for all cancer related deaths among men and women together and third for either sex when considered separately disparities exist in crc incidence and mortality between rural and urban counties in the usa this study sought to explore socioeconomic and behavioral factors that may partly explain these observed differences methods using educational and income levels as measures of socioeconomic status ses and average alcohol consumption and smoking frequency as behavioral factors data from the behavioral risk factor surveillance system brfss and the surveillance epidemiology and end results seer program were coupled for analysis results results showed statistically significant inequalities for crc incidence t 2675 p 0009 and mortality t 2328 p 0022 as well as socioeconomic ie poverty t 4864 p 0001 and behavioral ie smoking t 2777 p 0007 factors between selected rural and urban counties regression analysis for colorectal cancer incidence and mortality rates at the rural urban and national levels showed that smoking behavior was the strongest predictor while relative impacts of alcohol consumption and ses were observed conclusion health policies aimed at reducing disparities between rural and urban populations in the usa must therefore adequately address ses and behavioral factors

18942_0

introduction child labour is one of the most important global issues associated with povertyrelated life course negative outcomes such as health problems gender inequality exploitation and inadequate educational opportunities according to article 32 of the un convention on rights of the child child labour is likely to be hazardous or to interfere with the childs education or to be harmful to the childs health or physical mental spiritual moral or social development 1 child labour occurs in socioeconomically and psychosocially vulnerable poor families as poverty shifts from one generation to the next and also in workplaces where there are elevated exposures to health risks 2 3 4 bangladesh has 125 million child labourers who are economically active including domestic workers 5 work for most of them is an essential part of growing up and contributes to their family and its future prospects 6 mostly it is a willful strategy on the part of parents for acquiring money and food 7 child labourers can earn up to onethird of the family income and provide future as well as current security to their parents and families 38 there is a strong detrimental effect of child labour upon child health including psychosocial issues 39 there is evidence that work related injuries and health problems are very frequent among child labourers especially in the developing countries 911 however we need to focus on the magnitude of injury and health problems among child labourers child labour is a large problem in bangladesh 12 in the current study we have tried to explore the magnitude of injury problems among child labour in bangladesh through an injury surveillance system methods data from the prevention of child injuries through social intervention and education programme was analysed in this study this programme was one of the largest community trials for childhood injury prevention in developing countries precise programme the centre for injury prevention and research bangladesh with other partners developed and implemented precise a community based child injury intervention project this project was one of the largest community based injury intervention projects ever carried out in a developing country environment the overall goal of the project was to reduce child mortality and morbidity due to injuries through developing and implementing a comprehensive prevention program that could be scaled up throughout the country the precise method is available elsewhere and studies have already described it 13 the project had an inbuilt iss to monitor the interventions and to determine injury morbidities and mortalities and also to conduct cost analysis to determine what can be produced on a broader scale at an affordable cost study sites three upazilas from three selected districts of bangladesh were randomly selected for the iss these upazilas were raiganj from sirajganj district sherpur sadar from sherpur district and monohardi from narshindi district the districts were selected based on the high child injury rates as reported in bangladesh health and injury survey reports 14 in raiganj from the nine unions of this upazilas five were randomly selected for the surveillance system covering a population of 181 731 accordingly in sherpur sadar upazila seven unions were chosen out of 14 to fulfil the requirement of the needed population covering a population of 201 270 in another upazila manohordi eight unions were chosen from its 11 for the surveillance system covering a population of 185 920 data collection in january 2006 an injury and demographic surveillance system was introduced in three precise upazilas in rural bangladesh the iss began with a baseline census and then periodically captured all deaths and illnesses by facetoface interviews through household visits by surveillance data collectors the sdcs visited 6070 households on their assigned blocks each day the main objective of these regular visits was to identify all demographic and health events occurring in the surveillance area twelve precoded questionnaires were used to record data from each household on demographics health socioeconomic information and participation in injury prevention at the individual household level information on education and occupation for persons living in the household older than 5 years was collected the following operational definitions were followed throughout the surveillance period deaths all deaths which had occurred in the preceding one month and six months were registered for all age groups deaths were recorded in two categories injury and other when an injury death was diagnosed the detailed information relating to the death was collected causes of other deaths were not assigned beyond not injury injury deaths injury deaths included deaths from drowning road traffic burns falls poisoning suffocation choking animal bites hypothermia hyperthermia violence or suicide nonfatal injury the operational definition of nonfatal injury in this iss was any injury that required medical care or incurred at least a 3day absence from work or school or the inability to do normal daily activities as with deaths all illnesses are recorded in two categories injury and others for all age groups if any illness occurred due to injury was reported then detailed information on the injury morbidity was collected child labour study in the current study magnitude of injury deaths and illnesses was measured through analyzing the surveillance data of precise children within our operational definition were assigned as being child labourers at their first enrollment in the surveillance system this child labour cohort was then followed up to the end of surveillance at the end of 2010 child labour has been defined according to following criteria defined by the ministry of labor bangladesh government children aged between 6 and 17 years the reported principal occupation agriculture skilled and unskilled labour servant vanrickshaw puller service and household work mortality and morbidity of child labour has been registered only when that happens within childhood that is before 18 years of age at the date of occurrence children who died or migrated or crossed the age limit were excluded from the analysis exposure time to child labourer exposure time has been calculated from the date of enrollment to the end date of surveillance or death or date at which the individuals could no longer be classified as being children informed consent was obtained from all participants the analysis of the data was also approved by the institutional review board of ciprb results in total 42 487 child labourers were identified in the study of 144 157 households in the selected areas children aged 1517 years constituted the major percentage of child labourers girls were mostly employed as domestic workers within girls occupations in total 543 girls among both boys and girls were employed at domestic work the majority of boys were occupied in unskilled sectors more than one third of child labourers had primary education table 4 demonstrates that incidence of injury related illness per 100 000 children years was highest among the 69 years age group while deaths per 100 000 children years was highest among the 1014 years age group child labourers aged between 16 and 17 years had the second highest incidence of injury related illness and injury related death per 100 000 children years magnitude of injury problems among child labourers the highest number of injuries were cuts and open wounds followed by abrasions or lacerations sprains burns and animal bites table 5 indicates that incidence of injury morbidities per 1000 children years was highest due to cutsopen wounds followed by abrasions or lacerations sprains burns and animal bites table 6 demonstrates that suicide constituted the highest numbers of deaths among child labourers road traffic injuries were also an important risk factor for deaths of child labourers followed by electrocution other causes of deaths among child labourers were violence and drowning discussion the current study to the best of authors knowledge has for the first time used an iss to identify injury related illness and death issues among child labourers in bangladesh the surveillance found that almost 30 of children are involved in an occupation that identified them as child labourers the average age of child labourers is 15 years the risk of dying from injuries among child labourers was 24 per 100 000 children per year it is clear that boys work as unskilled labourers in the absence of proper professional training whilst girls work in the domestic field in order to help their mothers and to take care of other home affairs 3 the current study has confirmed the same trend of child labour in relation to gender issues the study also indicated that more than twothirds of child labourers are educated to primary or secondary level and only 31 are illiterate a nigerian study indicated that 68 of child labourers had a primary education and 51 had a secondary education 15 this finding has great policy implications for example policy makers could encourage professional training to encourage the production of more skilled labourers which would reduce their dependence upon unskilled low paid work our findings also contradict previous findings from the 1990s that child labour is mostly associated with a lack of education 16 this could indicate a shift in the educational trend during the last decade even child labourers are getting basic education ie those from the poorest segment of society child labourers aged under 10 have the least exposure to but the highest incidence of injury related illness while their older peers have the highest incidence of injury related death cuts and wounds are the main cause of injury related illness this is obvious with the under 10 age group at this age the children have not developed the sense for safety especially in the work arena policy makers could adopt safety awareness camps or produce safety instruction manuals for the child labourers to help prevent injuries 17 the current study indicates that the incidence of injury related illness among 617 year old child labourers was 191 in bangladesh whilst a small sample study from pakistan indicates that 34 of child labourers had injuries 18 such differences might be due to the operational definition of injuries the study has some limitations first of all the definition of child labour has been adopted from that of the government of bangladesh secondly recall bias of the respondents may underestimate the incidences of injury such bias may have been minimised in the authors contributions kd and fr were responsible for conceptual design and all authors were involved in data analysis kd drafted the manuscript and all authors revised and approved the final manuscript kd is the guarantor of the paper competing interests none declared

background child labour is an important topic in contemporary society in this study we have tried to explore the magnitude of injury problems among child labourers in bangladesh using an injury surveillance system methods an injury surveillance system iss was performed under the prevention of child injuries through social intervention and education precise project in bangladesh during 20062010 in three subdistricts covering a population of more than 700 000 we used the iss for assessing child labour appropriate epidemiological methods were considered in the study results considering the reported main occupation of the children 30 of children from the surveillance households were identified as child labourers more than two thirds of child labourers were educated to primary or secondary level the majority of boys worked as unskilled labourers and girls were employed in domestic work the incidence of injury and deaths among child labourers was estimated as 24 per 100 000 children years more than 19 injury related illnesses of moderate to severe intensity were found among 1000 child labourers in a year fractures sprains dislocations cutswounds animal bites abrasions or lacerations burns head injuries and internal organ injuries are most common among child labourers conclusions working children are at risk of injury death and illness in bangladesh child labourers are now even more clearly tied to quantified morbidity and mortality

18943_0

introduction cardiovascular diseases currently represent a serious public health problem worldwide being the main cause of morbidity and premature mortality by 2025 more than 80 of all cases of cardiovascular diseases and diabetes are expected to occur in middle and lowincome countries 1 cardiovascular risk factors are conditions associated with early onset cardiovascular disease some of these risks are not amenable to change such as sex age and heredity others may be changed such as smoking hypertension dyslipidemia obesity diabetes mellituscarbohydrate intolerance sedentarism psychosocial stress and some factors related to hemostasis inflammation and thrombosis recently considered to be crf 2 socioeconomic status is defined as the position a person occupies in the society to which heshe belongs measured according to income occupation andor education some studies have demonstrated an association between ses and crf 34 researches conducted in highincome countries have demonstrated that highincome persons have a lower cardiovascular risk whereas lowincome ones present a higher cardiovascular risk these differences in cardiovascular risk factors between the wealthy and the poor are attributed to the epidemiologic transition 4 5 6 the epidemiologic transition that started in the past century in highincome countries seems to be characterized in its initial phase by a worse cardiovascular risk in the highincome groups of the population in its intermediate phase this difference seems to disappear resumo introdução em países de alta renda indivíduos de situação socioeconômica elevada apresentam menor risco cardiovascular em países de média e baixa rendas os resultados são controversos objetivo avaliar a associação entre renda familiar e fatores de risco cardiovascular em adultos jovens metodologia estudo seccional em que foram avaliados 2063 indivíduos aos 2325 anos de uma coorte de nascimento iniciada em 197879 na cidade de ribeirão preto brasil avaliaramse fatores de risco cardiovascular de acordo com renda familiar a renda foi avaliada em múltiplos do salário mínimo as razões de prevalências foram estimadas em modelos de regressão de poisson simples com estimativa robusta da variância resultados mulheres de maior renda apresentaram menores prevalências de hdl colesterol baixo obesidade total e abdominal resistência insulínica pressão arterial elevada sedentarismo síndrome metabólica e alta ingestão calórica os homens de maior renda apresentaram menores prevalências de hdl colesterol baixo e sedentarismo pode ser que mulheres de alta renda prestem mais atenção aos hábitos saudáveis e aquelas com menor renda têm menor probabilidade de acessar recursos e tratamentos de serviços de saúde conclusão as mulheres encontravamse na fase final da transição epidemiológica enquanto os homens na fase intermediária palavraschave fatores de risco doenças cardiovasculares adulto jovem renda rev bras epidemiol 2020 23 e200001 due to a worsening of cardiovascular risk in poorer persons while wealthier persons would continue to have an unchanged and unfavorable cardiovascular risk in the final phase of this transition there seems to be an inversion in the relation between income and cardiovascular risk that would lead to a lower cardiovascular risk in the wealthier population and a higher one in the poorer population 78 studies conducted in middleincome countries in addition to being scarce have reported controversial results one research demonstrated a higher cardiovascular risk among highincome persons 9 while another concluded that the cardiovascular risk was lower among wealthier people 10 it is still unknown whether the inversion of the association between ses and crf observed in highincome countries has already occurred in middleincome countries 11 the objective of the present study was to determine whether highincome persons have a lower cardiovascular risk than lowincome ones from a birth cohort reassessed at 23 to 25 years of age in ribeirão preto brazil the question was had the epidemiologic transition been concluded or was it still in its intermediate phase in the city of ribeirão preto in 200204 methods study design the present investigation was a crosssectional study based on data from a birth cohort started in ribeirão preto brazil in 197879 this cohort is entitled perinatal health in ribeirão preto são paulo brazil and included liveborn singletons delivered at hospitals by mothers residing in the municipality from june 1 st 1978 to may 31 st 1979 the persons who participated in the first phase of the research were evaluated at other times ie at school age when they were 8 to 11 years old at the time of the military draft and at the age of 23 to 25 years this study used data collected at young adult age from april 2 2002 to may 12 2004 sample a total of 9067 mothers of liveborns were first interviewed in 197879 representing 98 of the total number of liveborns in ribeirão preto during the study period children whose mothers did not reside in the city and twins were excluded thus 6827 liveborns were included in the first phase a new evaluation was performed from 2002 to 2004 when the subjects were 23 to 25 years old the following procedures were used to locate the cohort subjects search of the addresses in the original birth charts enrollment in schools rev bras epidemiol 2020 23 e200001 inscriptions in health plans and in the unified health system military service and search in the telephone list the survey revealed that 343 subjects had died and 819 were not identified with 5665 subjects thus having been located this group was submitted to systematic selection with the first of each three names being selected according to birth date and geographic region of the city if the selected subject was not available the next name down on the list was chosen 705 subjects were lost to followup due to the following reasons refusal to participate detention death after 20 years of age or failure to attend the interview the losses were replaced using the same systematic selection resulting in 2063 subjects in addition 151 young adults were excluded because no information was available about their family income thus the final sample for the present study consisted of 1912 young adults power analysis for this study the power was 869 to detect a 10 difference in the prevalences between the compared groups for prevalences that were around 50 the study power was 828 to detect a 5 difference between the groups for prevalences around 10 assuming a 005 significance level study variables the family income of the young adults was determined using a question about this topic during the month preceding data collection all sources of family income were considered salaries investment money property income donations by relatives and any others the variable family income did not consider the number of family members the absolute values of this income were calculated as multiples of the brazilian minimum wage for each period and income groups were categorized as less than 5 mw 5 to 99 mw 10 to 199 mw and 20 mw or more the participants were submitted to physical examination and to blood collection performed by a doctor and a trained practical nurse a 40 ml blood sample was obtained aseptically from the cubital vein after a fast of at least 12 hours for the determination of fasting glycemia and total cholesterol and fractions university hospital faculty of medicine of ribeirão preto universidade de são paulo the samples were processed and analyzed in the laboratories of the hcfmrpusp by the enzymatic colorimetric method using a dade behring xpand instrument and dade behring dimension chemical reagentsfasting plasma insulin and glucose were used to estimate insulin resistance 12 rev bras epidemiol 2020 23 e200001 blood pressure was measured three times 13 using a digital sphignomanometer adjusted to arm circumference the same evaluator made the measurements at 15minute intervals with the subject sitting and holding his left arm at the height of the heart the mean value of the last two measurements was considered for analysis for the physical examination the participants wore light clothing and were barefoot weight was measured with a mechanical scale calibrated before each weighing with 50 g precision height was measured with a harpenden model wood stadiometer with 01 cm precision with the subject standing up body mass index was calculated as weight divided by height squared waist circumference was measured with an inextensible metric tape positioned on the smallest circumference between the iliac crest and the last rib this measurement was performed at the end of a normal expiration with the subject standing up with a relaxed abdomen total daily caloric intake and percent ingested fat were calculated with the dietsys software version 40 based on information obtained with a food frequency questionnaire validated for the brazilian population 14 physical activity was determined using the short version of the international physical activity questionnaire 15 smoking habit during the last 30 days was also obtained with a questionnaire the following variables were determined homeostatic model assessment of insulin resistance total cholesterol lowdensity lipoprotein cholesterol highdensity lipoprotein cholesterol triglycerides fibrinogen diabetes high blood pressure waist circumference excessive caloric intake 17 smoking practicing physical activity and total obesity when bmi was ≥ 30 kgm 2 the criteria of the joint interim statement were used to classify the metabolic syndrome 18 the jis considers ms to be present when three or more of the following five factors were detected abdominal obesity when wc is ≥ 90 cm for men and ≥ 80 cm for women hypertriglyceridemia low hdlcholesterol levels systemic arterial hypertension and high fasting glycemia the framingham score was applied in order to determine the risk of death due to coronary disease the framingham risk equation was computed as the probability of developing a coronary event within 10 years according to sex based on the following parameters age total cholesterol hdlcholesterol smoking systolic arterial pressure diastolic rev bras epidemiol 2020 23 e200001 arterial pressure and diabetes the risk of death due to coronary disease is low when less than 10 moderate from 10 to 20 and high when more than 20 19 this score was used as a continuous variable statistical analysis the data were weighted because of differential sampling losses at 23 to 25 years inverse probability of selection weighting was estimated by logistic regression based on birth weight parity preterm birth marital status maternal smoking maternal age maternal schooling family income and maternal occupation groups with lower followup rates were given greater weights whereas the ones with higher participation rates were given smaller weights trying to recreate the original composition of the cohort at birth the independent variable was family income and the dependent ones were the cardiovascular risk factors to determine the associations between family income and the cardiovascular risk factors the χ 2 test was applied to the categorical variables and analysis of variance or the kruskalwallis test was applied to the numerical variables p value for trend was also calculated for all cardiovascular risk factors simple poisson regressions with robust estimation of standard errors were performed to determine the association between family income and cardiovascular risk factors with the level of significance set at 005 no adjustment for confounding was performed since socioeconomic factors are distal factors in the theoretical model because we wanted to estimate the total effect it would not make sense to adjust for mediators we also did not adjust for age because the subjects were in a narrow age range all analyses were stratified by sex giving that a previous study conducted on the same sample had indicated that the associations between family income and adiposity varied between sexes 20 the stata ® 140 software was used for the analyses ethical and legal aspects the study was approved by the research ethics committee of hcfmrpusp and all subjects gave written informed consent to participate results when comparing the cardiovascular risk factors according to sex women showed higher prevalences of diabetes low hdlcholesterol high fibrinogen high caloric intake smoking and sedentarism whereas men presented rev bras epidemiol 2020 23 e200001 higher prevalences of high homa ir high triglycerides high blood pressure and metabolic syndrome in addition the framingham score was higher among men compared to women the young adult women belonging to the low family income group had higher prevalences of insulin resistance low hdlcholesterol total obesity abdominal obesity ms and high caloric intake as well as a higher prevalence of sedentarism the median cardiovascular risk measured by the framingham score was low but higher among lowincome women compared to all others lowincome young adult men had a higher prevalence of low hdlcholesterol and sedentarism the framingham score was very low for all groups in the poisson regression models the young adult women and men belonging to the lowincome group were used as reference highincome women had lower prevalences of insulin resistance low hdlcholesterol high blood pressure total obesity abdominal obesity high caloric intake and sedentarism highincome young adult men had lower prevalences of low hdlcholesterol and sedentarism discussion the present study investigated the associations between family income and cardiovascular risk factors among young adults participating in a cohort study in the city of ribeirão preto são paulo brazil highincome women showed a lower prevalence of insulin resistance low hdlcholesterol abdominal obesity total obesity high blood pressure metabolic syndrome high caloric intake and sedentarism highincome men presented a lower prevalence of low hdlcholesterol and sedentarism the strong points of the study were the large sample size and the use of various cardiovascular risk factors blood pressure lipid profile obesity metabolic syndrome dietary consumption physical activity smoking diabetes and insulin resistance using the homair model currently accepted for the identification of insulin resistance among young people in addition few studies about these aspects are available in low and middleincome countries among the limitations of the study is the fact that even though this is a birth cohort study in this analysis only crosssectional data were used another limitation was the use of family income as the only indicator of the socioeconomic status of the subjects without considering education however schooling did not have a discriminatory power since most subjects had a similar educational level additional possible limitation could be selection bias since subjects with a lower income at birth had lower participation rates in the followup than subjects with a higher income at birth this greater loss of data regarding income among poorer subjects may have prevented the detection of some differences or may have underestimated the associations presented here in addition some data about family income were missing in the statistical analysis inverse probability of selection weighting was performed trying to mitigate selection bias the present results showed that lowincome women had a worse cardiovascular profile than highincome women seven of the 15 cardiovascular risk factors investigated were more prevalent among lowincome women who also had a worse framingham cardiovascular homa ir homeostatic model assessment of insulin resistance ldl lowdensity lipoprotein hdl highdensity lipoprotein risk score for men only two of the 15 factors investigated were more prevalent among lowincome subjects in addition there was no difference in the framingham cardiovascular risk score among men thus it can be seen that the epidemiologic transition observed in ribeirão preto a city in a middleincome country occurred in a different manner according to sex for women the socioeconomic gradient of cardiovascular risk had already become inverted for almost the greatest part of the risk factors studied suggesting that these women are already in the final phase of the epidemiologic transition and for men the socioeconomic gradient of cardiovascular risk became inverted only regarding two of the risk factors studied suggesting that men are in the intermediate phase of the epidemiologic transition in this transition the cardiovascular risk factors are first concentrated among highincome persons in highincome countries since these persons come in earlier contact with the modern lifestyle later some factors such as behavioral nutritional and educational changes access to health services and a greater practice of physical exercise lead to a reduction of these cardiovascular risk factors in the highincome population and finally start to affect lowincome persons by leading them to a worsening of their cardiovascular risk factors 782122 in middleincome countries the process of epidemiologic transition started at a later time than in highincome countries in addition there is the fact that this transition may occur in a different manner at each location in middleincome countries as observed in the present study in which the transition was faster and the association between income and worse cardiovascular risk was inverted only among women 923 an indian study on a population of an age similar to that of the present one detected a worsening of risk factors among their highincome subjects 9 whereas a study conducted in the united states on a hispanic population revealed that despite the older age of the sample highincome was associated with a reduction of risk factors 24 the same has been found among elderly residents in são paulo brazil where lowincome groups had higher cvd risk 25 the highincome women studied here showed a lower cardiovascular risk and completed the epidemiologic transition process before the men did this fact may have been due to the greater concern of these women about consuming less caloric foods thus their greater access to information and better financial conditions favor a healthy and balanced diet 25 on the other hand lowincome women showed a higher caloric intake and were more sedentary a fact that may have contributed to their higher prevalences of total obesity and abdominal obesity and of other cardiovascular risk factors 26 the greater practice of physical activity by highincome young adult women may be explained by their greater concern about having a pleasant and healthy body thus due to their greater health awareness they adhere better to the practice of physical activity this may have contributed to the fact that their bmi values are lower with consequent lower prevalences of obesity and higher hdlcholesterol 27 in agreement with another study highincome women also showed lower prevalence of insulin resistance 28 although the prevalence of diabetes is low among young adults the lower presence of insulin resistance favors lower odds of developing diabetes the highincome rev bras epidemiol 2020 23 e200001 women in the present study also showed lower prevalence of ms which placed them in a situation similar to that encountered in higher income countries 29 higher income women exhibited a better cardiovascular risk profile than men belonging to the same income class a result in agreement with a study conducted in the united states 30 this may be explained by the fact that highincome women pay more attention to a healthy diet to weight reduction and to physical activity with their education possibly having positive effects of an economic and psychosocial order and protecting against adverse situations kandasamy and anand 31 pointed out that because of the genetic and hormonal characteristics and contraceptive use women have higher risk of increased cardiovascular risk factors and cardiovascular diseases when compared to men in addition to these risks these authors affirm that being a woman and having low family income induce more problems and risks often due to an array of social and structural circumstances such as fragmented health care social isolation language difficulties violence caregiving burden stress at home and early childhood adversity besides that those with the lowest family income are least likely to access health services resources and treatments conclusion lowincome women had a worse cardiovascular risk than highincome women in agreement with the epidemiologic transition that has occurred in highincome countries in contrast among men there was no difference in cardiovascular risk according to family income suggesting that men are still in the intermediate phase of the epidemiologic transition although the present sample consisted of a young population the prevalence of some cardiovascular risk factors was already high authors contribution fernando alberto costa cardoso da silva contributed to the interpretation of the data to the drafting of the draft to the critical review of content and participated in the approval of the final version of the manuscript maylla luanna barbosa martins contributed to the analysis of the data to the interpretation of the data to the drafting of the draft to the critical review of content and participated in the approval of the final version of the manuscript heloisa bettiol and viviane cunha cardoso and marco antonio barbieri contributed to the design and planning to the critical review of content and participated in the approval of the final version of the manuscript antônio augusto moura da silva contributed to the design and planning to the analysis of the data to the interpretation of the data to the drafting of the draft to the critical review of content and participated in the approval of the final version of the manuscript © 2020 associação brasileira de saúde coletiva this is an open access article distributed under the terms of the creative commons license

in highincome countries persons of high socioeconomic status ses have a lower cardiovascular risk however in middle and lowincome countries the results are controversial objective to evaluate the association between family income and cardiovascular risk factors in young adults methods a total of 2063 individuals of a birth cohort initiated in 197879 in the city of ribeirão preto brazil were evaluated at age of 2325 years cardiovascular risk factors hypertension sedentary lifestyle smoking low highdensity lipoprotein hdl cholesterol high lowdensity lipoprotein ldl cholesterol high fibrinogen insulin resistance diabetes abdominal and total obesity and metabolic syndrome were evaluated according to family income income was assessed in multiples of the minimum wage simple poisson regression models were used to estimate the prevalence ratios pr with robust estimation of the variance results highincome women showed lower prevalences of low hdlcholesterol pr 047 total obesity pr 022 abdominal obesity pr 028 high blood pressure pr 028 insulin resistance pr 057 sedentary lifestyle pr 047 metabolic syndrome pr 024 and high caloric intake pr 071 p 005 highincome men showed lower prevalences of low hdlcholesterol pr 073 and sedentarism pr 081 p 005 these results may be explained by the fact that highincome women pay more attention to healthy habits and those with the lowest family income are least likely to access health services resources and treatments conclusion women were in the final phase of the epidemiologic transition whereas men were in the middle phase

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introduction government of a country plays a very important role when it comes to providing social security to those who are living at the bottom of the pyramid of a society most of the policies of the government of various countries are focused on international migration for india where a huge number of people migrate every year from one place to another in search of work it is very important to have a robust mechanism in place which can strengthen the lives of labor migrants from socioeconomic point of view today living conditions of labor migrants have changed drastically as compared to their condition in 1980s 1990s yet a large number of labor migrants are not being able to avail the benefits of the schemes of the government labor is a concurrent subject and belongs to concurrent list of the constitution which means that both the centre and the state government can make laws on it in the wake of covid many states changed their labor laws as per the convenience of the business units and production units many such steps such as long working shifts by the laborers lesser welfare measures for the labor migrants invited critique by the stakeholders involved review of literature ursula kulke ilo geneva in filling the gap of social security for migrant workers ilos strategy has pointed out the importance of social security schemes to the labor migrants especially in the wake of economic integration social security schemes can be seen as incentives to the migrants thus motivating them to better integrate themselves in the labor market marius oliviera and avinash govindjeeb in protecting and integrating migrant workers in asean social security systems have talked about the role social security schemes can play in the region helping especially the low skilled or unskilled laborers whose income is low and thus who cannot afford social insurance schemes easily prof ockert dupper in migrant workers and the right to social security an international perspective has emphasized that in the era of globalization a large number of people are on move moving to other countries for better work opportunities and in such a scenario it is important to put emphasis on providing social security schemes to the migrant population review of literature puts light on the importance of social security schemes in the labor market especially for the ones who are low skilled dont have better income and are dependent on government for the provision of such benefits in the present paper we will look at the status of social security schemes as availed by labor migrants and the benefits they have taken out of those schemes research methodology it is an empirical exploratory and quantitative study it aims to know the number of labor migrants who are currently taking the benefit from social security schemes it aims to find out the benefits labor migrants have taken out of these social security schemes the universe of the study is all the labor migrants working in jammu a sample of 20 respondents is taken using purposive sampling method whereby respondents are chosen from all occupational sectors such as ones working in industrial sectors brick kiln units construction sectors selfemployed and fruit and vegetable vendors unit of analysis for the study the unit of observation is a migrant household the head of the family is interviewed primarily and wherever required other household members are also asked questions data was collected using interview schedule where the information gathered was personally filled by the researcher social security schemes and the migrant laborers social security schemes include the provisions provided by the government to provide social security benefits to its citizens like health education pensions cover life cover accident insurance and other basic facilities of life in this research paper we will try to know about the number of labor migrants availing the benefit of the social security schemes along with the impact following social security schemes have put on the life of labor migrants who have migrated and are working in jammu • atal pension yojna • pm jeevan jyoti bima yojna • pm suraksha bima yojna • pmjay • janani suraksha yojna • pm awaas yojna • food security atal pension yojna it is a government backed pension scheme in india which allows to have pension benefits to the ones who dont have any association with formal institutions introduced in 2015 it aims to provide social security to all the indians especially to the poorer ones who work in informal sector thereby covering the labor migrants also this scheme which allows some monetary safety for the workers at the age of 60 was availed by only 20 of the respondents while 80 of the respondents were either not interested in any of the social schemes or were not aware of the scheme pm jeevan jyoti bima yojna this scheme gives the provision of risk coverage of rs2 lakh of the insurer in case of death due to any reason premium to be paid to avail the scheme is of rs330 and the age group eligible for the same is 1850 years no 14 70 total 20 100 source collected from field survey 2023 6 respondents of the total respondents had availed the scheme while 14 respondents ie 70 of the total respondents had not availed it the main reason for not availing the scheme as per the respondents was not holding a bank account in any bank as it requires few legal documents like aadhar card in the absence of which a person cannot hold an account in a bank pm suraksha bima yojna this scheme is available for all those who belong to the age group 1870 years and it gives the provision of rs2 lakh as risk coverage for accidental death and upto rs1 lakh for partial disability premium of only rs12 is to be paid in this scheme annually 35 of the respondents ie 7 of the total 300 respondents had availed pm suraksha bima yojna and 57 had not availed it again a very small percentage of labor migrants had availed the scheme and the ones who had availed the scheme were the ones who hold bank account in their native state pm jay pradhan mantri jan arogya yojana is a health assurance scheme and it aims to provide health cover of rs 5 lakh per family per year for secondary and tertiary care to the poorer section of the society no 8 40 total 20 100 source collected from field survey 2023 60 of the respondents possess pmjay card while 40 of the respondents dont possess the card the reason for high number of labor migrants holding pmjay card shows the importance of health among the labor migrants the increasing number of diseases among labor migrants and huge expenditure incurred on curing the diseases has lured many to have pmjay card janani suraksha yojna it is a government backed scheme to provide cash assistance along with delivery and postdelivery care of the mother it is a motherhood assistance program under national health mission and its aim is to increase the deliveries at the hands of trained asha workers 70 of the respondents ie 14 respondents out of 20 had their wives who had availed benefits under this yojna 6 respondents out of 20 ie 30 of the respondents had not availed any benefit under the scheme a high number of respondents had availed the scheme and the reason for same was that most of the women go back to their native places for their deliveries and in native places it was easier to get institutional help for delivery from health care centers pm awaas yojna pradhan mantri awaas yojana was launched in the year 2015 with the aim to provide affordable housing to all by 2022 it included both the ones residing in rural and urban areas no 6 30 total 20 100 source collected from field survey 2023 14 respondents out of 20 had availed housing benefit under pmay this shows that a good number of respondents who were not having their houses were able to get their shelter because of this scheme the rest of the respondents had not availed benefit under the scheme and the reasons for the same are • name not found in the secc list as per which government decides the shortlisted ones • joint ration card which disallows two brothers of the same family to own their respective houses only one house is allowed per ration card • there were few who were of the view that government officials are dishonest they ask for bribe so if they decide to make house and government does not help on time it would lead to cash crunch in their life national food security act2013 national food security2013 was enacted to provide food security to the citizens of the indian nation according to the provisions of the act food grains are provided to people at subsidised rates covering 75 of the rural population and about 50 of the urban population public distribution system of the country allows people to avail food at subsidised rates through fair ration shops and allows them right to life under article 21 out of the total 20 respondents 16 respondents were availing ration on the subsidised rates most of them were those who had their parents or other family members living in the villages so their family is availing ration things have started changing to an extent after the announcement of one nation one ration card scheme by the centre with this migrant workers are able to get benefit under aadhar linked ration card by getting access to ration in the states where they are working the higher percentage of workers either themselves or their families in the village availing ration show that most of them belong to bpl category in fact the ones who are not availing ration are the ones who either dont have their ration cards or they have some issues with dealers or they dont have aadhaar linkage or they dont need ration from the government as they have crop from their own fields conclusion this paper gives a brief account of the social assurance scheme being availed by the migrant laborers working in jammu their coverage the effect these schemes have created on the lives of migrant laborers the social security arrangement which the government creates for its citizens is particularly helpful to those who are living below poverty line and for whom it is difficult to make both ends meet the above mentioned findings show that the number of labor migrants availing different social security schemes is low most of the labor migrants are unaware of the schemes those who are aware of the schemes are not able to take benefit of the schemes due to various reasons these reasons need to be collectively addressed by both the centre and state government interstate cooperation can also be beneficial in terms of easing the life of labor migrants in the wake of covid19 and other endemic diseases health has been seen as very important subject matter by various stakeholders of the society in such a scenario proving social assistance in the form of social security schemes is very important by the government in addition to it public campaigns regarding same should also be held for widespread dissemination of information with increasing population and with increasing number of people on move it is important that social security schemes are provided and are availed by maximum number of labor migrants

the present paper gives a detailed account on the interventions made by the government in the form of social security schemes for the welfare of the labor migrants working in jammu it focusses primarily on the number of labor migrants who avail social security schemes provided by government and factors responsible for the same social security schemes can play a very significant role in the welfare of the labor migrants as they come for their benefit at very affordable costs involved a huge number of indian population is working as unskilled labor this population moves from one place to another in search of better work opportunities and for this group social security in the form of various schemes is very important to be provided by the government this paper analyses the same in the jammu region of jammu kashmir state

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background every year over 13 million people are killed in car accidents globally 1 and around 186300 children under 18 die annually in motor vehicle crash 2 mvc is the leading cause of unnatural deaths in children worldwide and a significant burden on the global economy 2 in the united states approximately 3 of all emergency department visits are due to mvc leading to deaths of children under the age of one 3 although the burden is decreasing in developed countries mvc deaths are increasing in developing countries 1 in comparison to western nations the gulf cooperation council region has significantly higher mvc and fatality rates the recorded road traffic fatality rate in 15 developed european nations has decreased from 135 deaths per 100000 populations in the 1980s to 55 mortality rates today in 2013 saudi arabia and oman had the highest number of fulltime equivalents in the gcc region followed by kuwait qatar the united arab emirates and bahrain in terms of population size and vehicle ownership the united kingdom had the lowest fatality rates 4 despite being a developed highincome country saudi arabia has a high burden of traffic injuries 5 according to the global burden of disease two types of injuries are among the top ten leading causes of death in saudi arabia transport injuries and unintentional injuries 6 mvc was the leading cause of injury and mortality in saudi children accounting for 606 of all cases they were most common in 13to 18yearolds 7 it kills 31 of infants aged 29 days to 5 years and 58 of children aged 6 to 12 years 7 aside from the risk of death nonfatal injuries in children can result in permanent disabilities that have a longterm impact on the populations health and healthcare utilization according to a world health organization report mvc is expected to be the leading cause of disabilityadjusted life years loss worldwide by 2030 8 according to some studies up to 70 of those injured in mvc sustain head injuries whereas facial injuries accounted for up to 11 9 when compared to other parts of the body head injuries are associated with a higher risk of morbidity and mortality in adults 1011 because of the immaturity of their skeletal system and the larger headtobody ratio the impact of mvc injuries is magnified in children 12 furthermore head injuries place a significant strain on healthcare facilities every year approximately half a million children in the united states suffer from a traumatic brain injury while in saudi arabia brain injuries account for approximately 166 of dalys with mvc accounting for 81 of them 1314 it is widely recognized that mvc injuries are preventable increasing passenger safety technology child safety regulations and safety measures have reduced infants and children deaths 15 there is a 50 75 reduction in child death rates when children are properly restrained in car seats and restraints that are sized for their age weight height and other physical limitations 16 17 18 19 20 according to the american academy of pediatrics infants and toddlers up to two years of age must sit in a rearfacing seat for children older than two years a forwardfacing seat with a harness should be used until the child reaches 29 kg when a child exceeds the forwardfacing weight limit the beltpositioning booster seat is used until the vehicle seat belt properly fits which is around 812 years old all children younger than 13 years old should sit in the back seat 21 investments in primary prevention aimed at reducing the burden of mvc lag behind in the gcc 22 a hospitalbased educational program was conducted in china to increase birthing mothers knowledge and use of child safety restraints the program resulted in more than 90 of mothers benefitted from the educational intervention leading to 20 increase in purchase of child safety seat for their babies 23 another study found that combining a public health education program with financial incentives to increase the use of vehicle restraints can be efficacious 24 according to the findings of previous studies parents of young children favour the use of digital resources due to their convenience and novelty they preferred using apps but they seem to retain more information from reading information booklets 25 these results indicated that car seat education programs helped parents learn more about how to use car seats correctly choose the right type of seat understand current rules and laws and what they need to do to ensure the childs safety in case of a crash 26 therefore the aim of this study is to assess the efficacy of a social media campaign on parents knowledge and use of car seat safety methods ethical considerations this study was approved by the institutional review board deanship of scientific research at imam abdulrahman bin faisal university all experiments were performed in accordance with guidelines and regulations of the declaration of helsinki informed consent was obtained from all parents who participated in the study study design and setting this study was an interventional prepost survey conducted to test the effectiveness of an online module in improving parents awareness and knowledge regarding car seats use face and contents validity and reliability were assessed during a pilot test prior to the conduct of the study the pilot test was conducted on a group of 30 participants and contents were modified based on its results study participants the study targeted parents in the gulf cooperation council who have children aged from birth to 12 years old no exclusion criteria were applied this study used a snowball sampling method where current participants invite other potential participants the recruitment began with posting the link of an online module on twitter telegram snapchat and spreading it on whatsapp groups sample size the sample size was calculated using an online calculator based on a previous study 27 we determined that a sample size of 200 would be appropriate to achieve our objectives of power is 80 ci is 95 and alpha is 5 with an adjustment to 300 to account for potential incomplete data and response error project preparation and data collection online modules were developed by the research team based on a previous study 15 and expert opinions the online module was developed by surveysparrow and the campaign logo was made with the procreate ® app the module was made in english and arabic versions it consisted of three sections the presurvey sect 1 included a nine demographic questions such as gender country of residence educational level income number of children and the childrens health status b three attitude questions regarding car seat useutilizing 5point likert scale ranging from strongly agree with strongly disagree c three opinion questions towards car seat safety using the 5point likert scale and d nine pretesting knowledge questions with multiple choice answers that included questions about type position and age of each car seat the intervention sect 2 educational material which included numerous videos describing the significance of using a car seat the options available to parents of both normally developing and disabled children as well as important usage recommendations this section included also photographs of each type of car seat with short and concise pieces of information furthermore the who findings on the use of car seats in reducing child mortality as well as international guidelines recommendations on child safety seats were presented via multiple short statements through the module the educational videos were done using keynote imovie and youtube ™ after completing sect 2 and transferring to sect 3 the participants were not allowed to go back to sect 2 in order to ensure that their pretesting knowledge scores is not influenced by the educational section the postsurvey sect 3 included nine posttesting knowledge questions which are the same pretesting knowledge questions and two feedback questions about participants opinion of the campaign which included 1 their willingness to use children car seats after the campaign and 2 if the campaign was useful each section had to be completed before moving to the next one and participants were not allowed to go back and redo any of the sections if they had already finished it and moved to the following one however participants were allowed to close the module and come back to it at their convenience without time restrictions parents of children with special needs were directed to answer questions regarding special needs car seats while parents of healthy children were directed to answer questions for car seats recommended for healthy children additionally parents were directed the educational material appropriate for their childs need those who were not parents or parents who did not have children in the specified age group were directed to exist the module after asking an eligibility question every persons right to privacy is upheld the users personal information was not collected immediately after finishing the survey each person was given a different ip address statistical analysis the data was collected and coded in an excel sheet the countif formula was used in excel to check for entry duplication based on ip address then the data was exported to spss for statistical analysis numbers and percentages were calculated for demographical and descriptive variables knowledge questions were given a score of one for correct answers and a score of zero for incorrect answers total knowledge score was calculated by summing the scores of all knowledge questions for each participant these scores were calculated for pre and post knowledge questions for each participant paired t test was used to compare pre and post changes in parental knowledge scores a p value of ≤ 005 was considered significant results reliability test the cronbachs alpha value of the survey demonstrated acceptable reliable results of 06 the demographics 303 of participants completed the campaign with majority were mothers and were from saudi arabia almost half of the participants had more than four children while majority of them had healthy children most parents had a university educational level or above and for mothers and fathers respectively about half of the participating parents had an income of more than 10000 saudi riyals attitude and practices regarding car seats use table 2 represents participants practices regarding car seats use with 888 of parents agreed that car seats should be used for all children and agreed that their babies shouldnt sit in their laps on the contrary762 disagreed that their children should sit in the back without car seats however 70 of parents agreed that there is a lack of awareness about the importance of car seats in their countries the majority of parents agreed on the importance of organizing awareness campaigns and having a law to enforce the use of car seats figure 1 shows the willingness of parents to use the safety seat after the campaign forty percent of participants indicated that they would use safety seats parental knowledge before and after the campaign table 3 shows item and overall knowledge scores before and after the educational material the overall mean knowledge score at baseline was 1164 ± 173 which was significantly improved after the educational content to 131 ± 169 in the postsurvey the highest item analysis score was knowledge about the correct position safety seat in the car while the lowest score was regarding the criteria of choosing the appropriate safety seat perceptions satisfaction on the campaign participants were asked to share their perceptions regarding the campaign and most of them thought that it was very helpful and they were satisfied with the contents provided discussion the goal of the present study was to measure the effectiveness of a social media educational campaign on parental knowledge and attitudes regarding safety car seats the social media educational campaign of the present study was well perceived by parents and resulted in an improvement in parental knowledge and attitude towards safety car seats it offers evidence that educational campaigns spread across social media can increase total knowledge significantly between the pre and postsurvey results there was also a significant increase in all nine knowledge question areas included in the assessment in spite of the increased enforcement of traffic laws in kingdom of saudi arabia motor vehicle crashes continue to be a major cause of disabilities and death in the community 25 28 29 30 saudi law requires parents to use safety equipment like car seats and seatbelts for their children however only 153 of drivers and passengers regularly use seatbelts 31 in a study conducted in ksa approximately 30 of children under 5 were restrained with the most common method being in the front seat and on an adult passengers lap another ksa study reported that 538 of the children were found to be riding without a seatbelt or safety seat in the back seat 17 on the contrary more than 90 of people using car seats and safety restraint systems in the united states and australia 2 the use of appropriate child car seats plays an important role in reducing childrens mortality due to car accidents however a study conducted in romania in strongly agree agree 247 fig 1 willingness to use the car seats after campaign education 2020 reported that the majority of drivers were aware of the existence of child safety restraint regulations and are using car seats for their children but they had less knowledge when asked about the appropriate age for car seats those who did not use car seats in the romanian study listed having less knowledge and financial reasons as reasons for not using car seats 32 another study done in china showed low number of parents who owned car seats while only 229 of them were using car seats especially those who had high knowledge towards safety measures 33 in unaizah ksa most of the parents didnt use car seats and their knowledge regarding their importance was considered low 15 therefore awareness of parents in ksa needs to be raised in order to keep their children safe while they are out on the road indeed the current research provides a program that was effective in boosting awareness among parents whom in general do not get this kind of campaign it is hoped that this would lead to a reduction in the wide discrepancy that exists in the rates of car seat use this research used a variety of learning tools to boost knowledge including videos messages and quizzes spread through social media platforms to reach large number of parents of different backgrounds social media is an effective tool that can be used to deliver information and spread knowledge in recent years it became a new platform for health promotion in many areas including smoking cessation exercising and diet 34 newsmedia campaigns that were conducted through radio television newspapers and internet have effectively motivated behaviours that reduced sportrelated injuries and injuries from car accidents 34 in addition to having a largescale audience social media allows sharing experience and interaction between users which makes it more influential than traditional campaigns 3435 because of the wide gap in car seat use rates the current research was carried out through an internet campaign in the hopes of narrowing that gap evidence suggests the effectiveness of combined interventions on child safety seats use for instance laws along with educational programs or communitywide enforcement campaigns with incentive while educationonly programs were found to be less effective 36 the results of this research study suggest that the majority of participants in the arabian gulf region were well educated mothers from saudi arabia furthermore most participants had an income of more than 10000 saudi riyals this is consistent with other studies conducted in the region which have found similar socioecenomic distribution of participants 152737 however this might have happened as a result of having an online campaign on social media where most its audience are from higher socioeconomic background a large specimen of the population who are from low socioeconomic background might have been excluded from benefiting from the educational program which is a drawback of this study their exclusion might not because of their lack of access it is mostly due to their lack of interest and willingness to participate in such programs more attention should be given to those who do not engage in online educational campaigns by inperson programs the results of this study found that the overall mean knowledge score of posttest was significantly higher than pretest the highest item analysis score was knowledge about the correct position safety seat in the car while the lowest score was regarding the criteria of choosing the appropriate safety seat these findings demonstrate that social media educational campaigns can be an effective tool for increasing parental knowledge attitude and practice of car seat use worldwide additionally it can be effective in increasing awareness and knowledge about healthrelated topics 3839 furthermore the high satisfaction rate reported by participants in this study indicates that such campaigns may be well received by parents in the arabian gulf region however further research is needed to determine if these effects are sustained over time and if they are associated with improved outcomes for children using car seats in this region or elsewhere study limitations and future directions it is important to note that there are some limitations to this study first this study relied on selfreported practices which may not reflect actual behaviours and may lead to questioning the reliability of the answers as overreporting is likely to occur such design is subjected to several types of bias such as selfselection bias and social desirability bias however it remains among the best available tools to assess the populations knowledge attitude and reported practices additionally the immediate assessment of improvement in knowledge may not necessarily mean maintaining longterm knowledge furthermore an improvement in knowledge does not guarantee a change in behaviour as most of our participants knew the importance of car seats but there was little compliance from parents the study included parents who had internet access which may not reflect the situation of those without internet access which could lead to selection bias however our study had participants from low socioeconomic status which indicates inclusivity of different backgrounds future research should look at the effectiveness of social media educational campaigns over a period of time to see whether they have sustained longterm impact this might be accomplished by conducting prepost questionnaires over a time lag additionally consider larger sample sizes and longer time frames to better understand the impact of social media furthermore monitoring parents capacity to appropriately install car seats after interventions might be useful in developing future programs conclusions this study provides evidence that implementing social media educational campaigns can be an effective tool for increasing parental knowledge attitude and practice of car seat use in the arabian gulf region the high satisfaction rate reported by participants suggests that such campaigns may be well received by parents in this region the use of social media campaigns might help overcome some of the limitations of prior studies such as lack of time and resources for reaching wide audience future research should consider larger sample sizes and longer time frames to better understand the impact of such campaigns on parental knowledge attitude and practice of car seat use in the arabian gulf region abbreviations all experiments were performed in accordance with guidelines and regulations of the declaration of helsinki informed consent was obtained from all parents who participated in the study competing interests the authors declare that they have no competing interests • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from

background motor vehicle crashes mvcs are the leading cause of child deaths in the gulf cooperation council this study aimed to investigate the effect of a social media educational campaign on parents knowledge of child safety seatswe conducted a prepost interventional study as an online educational module in arabic and english the module link was shared on social media and was accompanied by a prepost survey that included questions about demographics knowledge and practices of car seat use results a total of 303 participants completed the campaign with 238 fathers and 762 mothers answered the survey the majority of participants were from saudi arabia 957 while 43 were from other gulf cooperation council gcc countries most parents agreed on the importance of organizing awareness campaigns and having a law to enforce the use of car seats the presurvey mean knowledge score was 1164 which significantly increased to 131 in the postsurvey p 0001 the intervention of the educational campaign through social media resulted in a significant increase in parents knowledge and awareness of the importance of using car seats correctly this study highlights the potential effectiveness of social media campaigns in improving parents knowledge and awareness of child safety seats

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introduction life expectancy has almost doubled in the past century which has led to increases in joint survivorship within and across generations prolonged periods where both adult offspring and older adults are alive have increased the time where support can be exchanged between the generations 1 when older adults become dependent on care in old age eg due to decline in physical function adult offspring are the most common primary caregivers 1 this makes adult offspring important sources of emotional and practical support and various studies have shown that social relations are important for pf and longevity in old age 2 3 4 5 however the support that adult offspring can provide their parents may depend on their own socioeconomic resources recently the concept of social foreground has been introduced which suggests that the adult offsprings socioeconomic position may influence the health outcomes of their older parents 6 this hypothesis has been supported by a limited number of studies of late life mortality from middle and high income countries 6 7 8 9 10 11 but only two studies on pf from mexico and taiwan 12 13 no studies on the impact of the social foreground on pf in old age have been conducted in high income countries the mechanisms behind social foreground are not fully established but have been suggested to act through transfer of both material and nonmaterial resources based on berkman and glass theory on how social relations impact health torssander suggests that social support social influence and access to resources are three possible pathways of how the sep of adult offspring can influence older adults health 6 14 torssander has suggested that offsprings education influence older adults health by affecting the lifestyle use of healthcare and adherence to medical treatments of the parent 9 offsprings sep has been suggested to influence older adults health because stable and privileged labor market positions may provide benefits for more family members 9 also higher seps provide knowledge and contacts that are important for health and navigation within the health care system 9 furthermore flexible work hours related to certain seps may enable adult offspring to engage more in older adults contact with healthand eldercare 9 finally torssander suggested that offsprings income may influence older adults health through the provision of material resources and consumption potential 9 thus specific additional resources related to different aspects of the sep of adult offspring are suggested to support and promote older adults health in old age to elucidate whether the possible mechanisms linking social foreground to late life health depend on social contact between older adults and offspring studies should investigate whether older adults experience more health benefits from having offspring with high sep if they have high social contact and live geographically close to the offspring the contact frequency between adult offspring and older adults directly implies whether there is a basis for regular transfer of resources between them previous studies have not investigated the potentially modifying impact of social contact on the association between social foreground and health geographical distance between adult offspring and older adults also influence contact frequency and the possibility of facetoface contact 15 and in turn whether resources are likely to be regularly transferred between them this would support an explanation where regular transfers of resources from the adult offspring to the older parent is part of the mechanisms generating health disparities by social foreground if there is no difference between a c c e p t e d m a n u s c r i p t the older adults health depending on the geographical distance to or contact frequency with offspring this could imply that it is the possibility to draw on resources of adult offspring with high sep when needed rather than regular transfers of resources that drives the association between social foreground and health in later life the concept of social mobility is also important to study in relation to social foreground social mobility concerns the downward and upward intergenerational or intragenerational socioeconomic mobility and have previously been investigated in relation to the individuals own health 16 17 yet it is possible that offspring social mobility also influences the health of their older parents older adults may experience a status loss if their offspring experience downward social mobility whereas upward social mobility may lead to a feeling of status gain on the other side social mobility may create emotional distance between adult offspring and older adults in a recent commentary simandan describes how upward social mobility among individuals from disadvantaged backgrounds can result in social isolation and subsequent negative health consequences individuals who experience upward mobility may lose contact with individuals from their prior sep and negative emotions due to envy may dominate the remaining relations at the same time individuals who experience social mobility have to fit into their new sep 18 therefore intergenerational upward social mobility may lead to a stressful relation between adult offspring and their older parents which could cause adverse health outcomes for both generations whether and how intergenerational social mobility of offspring influences older adults health still needs to be investigated elucidation of the relation between intergenerational social mobility of offspring and parental health could explain whether social mobility leads to poorer health among older adults potentially due to generational conflicts the aims of this study are to investigate 1 how adult offsprings social class is associated with pf among older adults 2 whether geographical closeness and contact frequency with offspring modify the associations and 3 whether intergenerational social mobility of offspring is associated with pf of older adults methods data and study population data from the 2002 and 2011 waves of the swedish panel study of living conditions of the oldest old were utilized in this study the regional ethical review board in stockholm has approved study protocols the data were mainly obtained from facetoface interviews but proxy interviews were performed when the older persons were not a c c e p t e d m a n u s c r i p t able to answer themselves each wave comprises previous interviewed individuals from earlier waves and new enrolments to ensure that the sample represents the age distribution of the older segment of the swedish population including community dwelling and institutionalized older adults the participation rates were very high for both waves 19 the flow chart in figure 1 illustrates the selection of the study population based on 621 older adults from the 2002 wave and 931 older adults from the 2011 wave due to the focus on socioeconomic status of older adults offspring the study was restricted to older adults with offspring exposures the main exposure variable was adult offsprings social class at the time of the survey which was categorized using the official swedish socioeconomic classification similar to the widely used egpschema developed by erikson goldthorpe and portocarero 20 social class was dichotomized into the categories nonmanual occupation and manual occupation adult offsprings social class was based on the dominance approach where information from the oldest offspring with the highest social class is included the dominance approach originally described that the higher social class of a household tend to be more important than lower social classes for the lifestyle in the household 21 the mechanism may be similar for the impact of adult offsprings sep the variable was coded 0 nonmanual if any of the offspring had nonmanual social class and 1 manual occupation if all of the offspring had manual occupation when older adults had more than one offspring with nonmanual occupation the oldest offspring was included 212covariates the potential confounders are specified below  older adults own prior social class was measured by the main prior social class and categorized as 0 nonmanual and 1 manual occupation  older adults partners prior social class was defined by the main prior social class and categorized as 0 nonmanual 1 manual occupation and 2 no partner  age of offspring was included as a continuous variable  gender of offspring was categorized as 0 female and 1 male a c c e p t e d m a n u s c r i p t to investigate social and geographical closeness as potential effectmeasure modifiers two combined variables between offsprings social class and contact frequency and geographical closeness respectively were constructed  geographical distance was categorized as 0 live within 20km and 1 live more than 20km apart the cutoff at 20km was chosen because a geographical distance of more than 20 km has been associated with less facetoface contact between older adults and offspring 15  contact frequency between older adults and adult offspring was based on spending time andor having telephone contact and categorized as 0 weekly and 1 less than weekly for the analyses of social mobility of the offspring the variable intergenerational social class mobility of offspring was created based on a combination of the older adults and the offsprings social class intergenerational social class mobility was categorized as 0 stable nonmanual occupation 1 upward mobility 2 downward mobility and 3 stable manual occupation outcomes a pf index based on the ability to walking 100 meters briskly without difficulties and climb up and down stairs without difficulties was constructed 22 the index was categorized as 0 not able to walk 100 meters and climb the stairs without difficulties 1 only able to either walk 100 meters or climb the stairs without difficulties 2 able to both walk 100 meters and climb the stairs without difficulties the index was treated as a linear outcome with the values 02 thus we assume that the index represents an underlying continuous scale of pf analyses linear regression models were used to analyze the associations between offsprings social class and their parents pf the available data were weighted with the inverse probability of not being missing to adjust for the 133 individuals excluded due to missing values these probabilities were estimated in a logistic regression model with all the covariables as explanatory variables we tested whether the associations between the offsprings social class and their parents pf differed between strata of geographical distance and contact frequency in additional analyses by including corresponding interaction terms in the models observations were not independent because some participants were included both in 2002 and 2011 with updated information on all variables since 154 participants were included both in 2002 and 2011 a c c e p t e d m a n u s c r i p t the artificially inflated confidence due to repeated observations on the same participants was corrected by the use of a robust sandwich estimator for the variance using statas cluster command all analyses were also adjusted for survey year finally interaction between offspring social class and survey year for the outcome of pf was insignificant thus the analyses were not stratified by survey year results the baseline characteristics of the study population are presented in table 1 the mean pf was 11 on the scale from 02 in appendix table s2 shows that the distribution of the baseline characteristics was overall similar for the two waves of data with the exception that the population in the 2011 wave was older more often had prior nonmanual occupation and more often had offspring with nonmanual occupation table 2 shows that the proportion with limited pf was greater among older adults with offspring with manual occupation compared to older adults with offspring with nonmanual occupation table 2 shows unadjusted and adjusted estimates and 95 confidence intervals for the associations between offsprings social class from linear regression analyses the unadjusted analyses showed that older adults with offspring with manual occupation had 022 point poorer pf than older adults with offspring with nonmanual occupation the association was still adverse but the ci95 included the reference value of 000 after adjustment for potential confounders table 3 shows the effectmeasure modification of older adults geographical distance to and contact frequency with offspring on associations between adult offsprings social class and older adults pf in the adjusted analyses older adults with short geographical distance to their offspring had poorer pf when their offspring had manual compared to nonmanual occupation however test of interaction was insignificant there were no differences in estimates between older adults who had low or high contact frequency with offspring figure 2 shows adjusted associations between intergenerational social mobility of offspring and older adults pf compared to the reference of stable nonmanual occupation the estimates showed that especially older adults with downwardly mobile offspring were a c c e p t e d m a n u s c r i p t associated with poorer pf however also upward mobility and stable manual occupation were associated with poorer pf pairwise combination showed no differences between older adults with offspring with upward mobility downward mobility or stable manual occupation supplementary analyses a supplementary analysis of decline in pf from 20022004 and 20112014 restricted to older adults with full pf overall supported the main findings the second supplementary analysis included offsprings social class in six categories the results showed that compared to older adults with offspring with upper white collar occupation older adults with offspring with unskilled occupation were associated with the poorest pf this could indicate that the main results to some degree were driven by differences between those with the lowest and highest occupations also many older adults have more than one offspring and there are therefore several approaches to investigate the association between offsprings sep and older adults health outcomes we applied two additional approaches by the average and closest offspring approach the average approach analysis was based on a combination of all offspring this analysis showed that compared to the reference of older adults for whom all offspring had nonmanual occupation older adults for whom all offspring had manual occupation were associated with poorer pf older adults with offspring with mixed social classes were also associated with poorer pf however the ci95 included the reference the closest offspring approach was based on the oldest offspring who the older adults felt closest to the analysis showed findings overall similar to the main results finally older adults may move closer to offspring when experiencing decline in pf we investigated this among the 154 older adults included both in the 2002 and 2011 waves the majority did not experience change in the geographical distance to offspring between the two waves but 66 experience an increase and 99 experience a decrease in the geographical distance unadjusted analyses showed no statistically significant association between change in geographical distance to offspring and change in physical function discussion offspring socioeconomic position and older adults health a c c e p t e d m a n u s c r i p t the results showed that older adults whose offspring had manual occupations had poorer pf on average than older adults whose offspring had nonmanual occupations two previous crosssectional studies have shown that having offspring with high sep measured by education and financial status was associated with better pf among older adults first a study of 3795 older adults in taiwan showed an adverse gradient in the association between level of the highest educated offspring and the presence and severity of physical limitations the analyses were adjusted for parents own education income and the wealth of the household 13 second a study of 9661 mexicans aged 50 years and older showed that compared to older adults for whom all offspring had less than 12 years of education older adults whose every offspring had minimum 12 years of education had fewer functional limitations however there was no health advantage among the older adults who had offspring both with and without 12 years of education the study also investigated the impact of offsprings financial status and found similar results the analyses were adjusted for parents own education but not partners education 12 thus the estimates might be confounded by household socioeconomic resources in the current study the associations between offspring social class and older adults pf were based on a highincome context in sweden but similar associations have also previously been detected in middle and low income countries such as mexico and taiwan the associations were stronger in mexico and taiwan 12 13 compared to sweden which could indicate that the impact of social foreground depends on cultural norms family patterns and the degree of social support in the countries social foreground may be less important in a nordic context with high social security based on the welfare state and a universal healthcare system 23 ie in a setting where older adults may be less financially dependent on adult offspring in old age however it is important to note that offspring are important sources of social contact for older adults also in sweden in our study population 7580 had contact with their offspring every week overall the results from the present and previous studies imply that the impact of social foreground on health in old age exists in both high middle and low income countries though the reasons and degree of influence may vary between countries the majority of previous studies on the impact of offspring socioeconomic factors on older adults health have analyzed mortality the five previous studies from sweden usa south africa taiwan and china observed associations between higher education of offspring and lower mortality of older adults 69 13 the study by torssander furthermore investigated the association between three measures of adult offsprings sep by education income and social class and older adults a c c e p t e d m a n u s c r i p t mortality in sweden all three measures were adversely associated with older adults mortality yet the associations were greatest for education 9 geographical and social closeness as potential effectmeasure modifiers we found that the magnitudes of the associations were greater when older adults lived close to the offspring however the test of statistical interaction between offsprings social class and geographical distance were only significant at the 10 level the aforementioned taiwanese study found that the severity of physical limitations was greater when the offspring both had low education and lived far away compared to any other combination of the two variables 13 the associations did not differ depending on whether the older adults had low and high contact with the offspring no previous studies have investigated social contact as effectmeasure modifiers of the association between offspring sep and the health of their older parents lack of statistical power may explain the insignificant interaction analyses between offspring sep geographical closeness and contact frequency respectively geographical closeness and contact frequency may both facilitate transfer of resources related to the social class of the offspring but at the same time compensate for lack of resources related to a lower social classes level of the offspring intergenerational social mobility the study found support for the importance of intergenerational social mobility of offspring for the pf of their older parents older adults with offspring that experienced downward mobility had the poorest pf older adults with offspring who was upwardly mobile or had stable manual social class also had poorer pf than those whose offspring was not socially mobile yet this may partly be driven by the older adults own prior occupation the results that downward mobility was associated with the poorest pf could be explained by the possibility that older adults experience a status loss when offspring do not obtain the same social class as themselves the results for upward mobility may be explained by older adults with higher sep more easily adopt to new conditions and behaviors and thereby are able to take more advantage of the resources related to offspring with high sep 10 thus poorer pf among older adults whose offspring experience upward mobility may be explained by especially beneficial effects for the reference groups of older adults with prior nonmanual occupation whose offspring also have nonmanual occupation furthermore the act of upward social mobility of adult offspring may impact the generations relationship negatively as described in simandan upward social mobility a c c e p t e d m a n u s c r i p t among individuals from disadvantaged backgrounds can result in social isolation and negative relations with individuals from their prior sep 18 hence lack of support and connection with offspring could explain the findings of poorer pf among older adults whose offspring had experienced upward mobility in the mexican study of pf offsprings level of education only added to the impact of the older adults educational level 12 studies on mortality have found conflicting results the american study found no interaction 10 whereas the chinese study showed that low educational level of adult offspring was associated with greater mortality when fathers had high compared to low educational level 8 in contrast the taiwanese study showed that survival of older adults with middle or high education benefited most from having highly educated offspring 7 diversity in the findings may be explained by different cultural and societal settings given the limited number of studies intergenerational social mobility still needs to be investigated in relation to the concept of social foreground correlation and causality as also mentioned in previous studies the observed associations between offsprings sep and the older adults health may not necessarily express a causal relationship the associations could be confounded by unmeasured factors such as the older adults cognitive ability in midlife and personality traits that favor longterm investment which are factors that influence education and later sep of offspring and the older adults own health 6 12 we adjusted for the parental and parental partners prior social class to account for this two previous studies have furthermore tried to account for unmeasured confounders first a study by torssander addressed unmeasured confounders by using fixedeffects models where parental siblings were compared to adjust for shared and unmeasured familial background in these analyses with adjustments for all potential unmeasured confounders related to familial background significant association between higher educational level of adult offspring and lower mortality of older adults was detected 6 hence the previous study by torssander provides evidence that the associations between social foreground and older adults mortality could express a causal relationship second lundborg and majlesi used an instrumental variable design to account for confounding the study used the gradual implementation of increase in number of mandatory years of schooling from seven to nine years in sweden during the period 19491962 as an instrument for differences in offsprings education the study found no association with older adults mortality with the exception of a subanalysis that showed adverse association between sons education and mothers survival 24 this could imply that the impact of adult offsprings education on older adults survival only apply when comparing greater educational a c c e p t e d m a n u s c r i p t differences and not two additional years of elementary school these results do not necessarily suggest that there is no causal effect of offsprings education on older adults health the results merely suggest that a potential positive influence of education on health only apply at higher levels than elementary school more studies should seek to use quasiexperimental designs to further disentangle the causal relationship between offspring sep and older adults health finally given the crosssectional nature of the study the detected associations may express reverse causality there is a possibility that older adults who had poorer pf have had this throughout their lives which in turn may have influenced their offsprings socioeconomic opportunities this could be the explanation for the associations detected for downward social mobility older adults who have had poorer health throughout their lives may have been less able to support their offspring in obtaining the same level of sep applying a longterm followup design would limit the risk of reverse causality however we believe that the risk of reverse causality is minor as decline in pf function generally does not occur until middle and old age where most offspring would have already obtained their adult sep strengths and limitations a major strength of this study is the extensive information about the study population and relationship with adult offspring which enables multiple approaches to define the exposure of offsprings social class in the main and supplementary analyses the high participation rate of 844 in 2002 and 862 in 2011 and inverse probability weighting of those excluded due to missing values decrease the risk of selection bias the information is obtained from facetoface interviews which improves the validity of the measures included in the study there are also some limitations to acknowledge even though the study population comprised 1186 older adults a larger sample size would improve the statistical power and thereby allow for stronger conclusions the observational nature of the study makes it impossible to draw conclusions about the causal nature of the associations as noted associations of offsprings sep and parents health could be confounded by unmeasured characteristics eg cognitive ability as described earlier we tried to minimize this potential bias by adjusting for own and partners previous social class also the cross sectional design of the analyses of pf could further reduce the potential for causal inference but this may be less of a problem for adult offsprings social class as most offspring probably enter the workforce before their parents reach old age where most pf limitations emerge also social causation is to some degree supported by the supplementary analyses of decline in pf showing similar results the crosssectional nature of the study may also be important for the interpretation of the influence of geographical distance it is likely that older adults and offspring move closer when the older adult a c c e p t e d m a n u s c r i p t experience limitations in physical function a supplementary analysis showed that there was a tendency however insignificant that older adults who experienced a decrease in geographical distance to offspring were associated with decline in physical function compared to the stable reference however it is important to highlight that the main results only show the potential effectmeasure modification of geographical distance on the associations between offspring social class and physical function of older adults thus not the direct effectmeasures associated with geographical distance finally especially information regarding the social class of offspring may be subject to misclassification as it is based on the older adults perception and memory however the misclassification is likely to be reduced when dichotomizing the variable in the broad categories social class on the other hand the broad categories yield substantial unmeasured socioeconomic heterogeneity that may lead to underestimations of the associations implications and future studies evidence of the impact of social foreground implies that socioeconomic resources available in older adults close family relations are important for their pf and health the results on intergenerational social mobility could imply that the dynamics and interplay between generations influence whether social foreground is important for older adults health preventive interventions and healthcare professionals that focus on socioeconomic inequality in health in old age should not only focus on the older adults own sep but also have attention to the socioeconomic resources in the older adults close network furthermore it is important to pay attention to the dynamics of older adults family relations and the amount of support that older adults receive from their offspring this study contributes with new results strengthening the evidence of the impact of social foreground on older adults health however additional studies are needed the validity of the results from the present study is limited by the observational and crosssectional study design future studies should seek to apply longterm followup designs to limit the risk of reverse causality and furthermore apply methods that more sufficiently account for residual confounding such as natural experiments instrumental variables and fixedeffects analyses5 conclusion older adults whose offspring had manual occupation had poorer pf on average than older adults whose offspring had nonmanual occupation in stratified analyses of older adults with short and long geographical distance to their offspring offspring with manual occupation was only associated with a c c e p t e d m a n u s c r i p t poorer pf among older adults that lived geographically close to the offspring the associations did not differ between groups of older adults with low and high contact frequency with offspring this study adds to the current evidence on social foreground and indicates that it is the possibility to draw on resources related to the social class of adult offspring when needed rather than regular transfers of resources that drives the association between social foreground and health in later life the study furthermore provides knowledge on how intergenerational social mobility seems to shape the associations between social foreground and pf of older adults compared to older adults whose offspring had stable intergenerational nonmanual occupation older adults with offspring who experienced downward intergenerational social mobility had the poorest pf on average however older adults with offspring who experienced upward intergenerational social mobility also experienced poorer pf on average a c c e p t e d m a n u s c r i p t a c c e p t e d m a n u s c r i p t a c c e p t e d m a n u s c r i p t conflict of interest none declared

 social foreground is an important aspect of health inequality in old age  geographical closeness strengthened findings of the impact of social foreground

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introduction a key challenge for environmental management is the number and diversity of the actors and sectors involved each with their own perceptions interests and resources to address this challenge multiple collaborative approaches have been developed such as adaptive management multilevel governance communitybased natural resource management network governance and collaborative governance despite their different foci they share a number of characteristics 1 they all address collaborations across organizational boundaries between diverse stakeholders such as governmental actors nongovernmental actors andor citizens 2 they all promise or expect better coordination between authorities and more integrated management 3 they all assume a shift from statecentered hierarchical topdown government towards less formalized governance by networks of interdependent stakeholders that extend beyond the government sector reasons given to collaborate include the limited resources of government government simply does not have all the information power and finances necessary for environmental management which makes it dependent on other stakeholders budget cuts over the past years have only increased this dependence moreover involving diverse stakeholders can increase public support reduce opposition and improve implementation of government policy and finally there is the moral argument that involving stakeholders makes environmental management more democratic empirical studies on the alleged shift from government to governance are scarce in england watson et al described how recent institutional reform in the water sector has actually strengthened control by state water agencies despite the use of language emphasizing partnerships and collaborative governance nonstate actors and local authorities have been given substantial roles in the implementation of management measures but the measures are still decided upon by national government and national government agencies who also control implementation rather than increasing democracy and responsiveness this has reduced public accountability because central government is able to deflect the blame when things go wrong the account given by watson et al raises a number of questions concerning the alleged shift from government to governance the aim of the present article is to shed some more light on this issue and describe the complexity of the current collaborative and crossboundary interactions between governmental and nongovernmental actors concerning environmental management using a case study approach the method used is social network analysis sna analyzes social networks in terms of a set of nodes and a set of ties between these nodes it can provide insight in the position and role of individual actors in the network and help to identify central coordinating and bridging organizations whose activities connect actors that otherwise would not have been connected the structure of ties between these actors gives insight in intra and intergroup collaboration finally overall network properties such as the number of ties compared to the number of possible ties give insight in the potential for collaborative action and structural cohesion in the network the case that will be analyzed is the maintenance of floodplains in the dutch rhine delta the multifunctionality of these floodplains leads to interdependence of stakeholders with respect to the different functions especially concerning flood protection and nature restoration both the blue network concerning flood protection and the green network concerning nature will be analyzed the following questions will be addressed which actors are involved and what are their collaborative relationships to ensure flood protection andor reach nature objectives which actors play a coordinating or bridging role what is the role of governmental versus nongovernmental organizations in both networks the next section presents the case study and the methodology used subsequently the results are presented the article concludes with a discussion and conclusions on the main research questions method case study floodplain management the case study that is central in this article is the maintenance of the floodplains of the river waal the main branch of the river rhine in the netherlands the case study area includes one province and 15 municipalities and covers a river stretch of 80 km or 152 km 2 the responsible authorities regarding flood protection are the state water agency which is responsible for the river itself and can regulate all activities in the floodplains that influence the water quality and quantity and the water boards which are responsible for the dikes and levees responsibility for maintaining and developing nature in the floodplains was decentralized in 2014 from the ministry of economic affairs which is also responsible for agriculture and nature policy to the provincial governments the provincial governments plan and implement eu natura 2000 objectives based on the european legislation and allocate subsides for nature conservation this may require changes in land use which is regulated by the municipalities alongside the authorities a variety of private individuals groups and organizations have an interest in the maintenance activities in floodplains these include nature conservation organizations farmers research institutes and sand gravel and clay mining industries the nature conservation organizations often deal with cultural heritage as well many farmers are also interested in maintaining biodiversity to be eligible for nature conservation subsidies they are organized in farmers associations which combine agricultural activities with nature conservation in the 1990s public and private stakeholders developed and implemented integrated plans to improve flood protection while restoring dynamic natural processes and safeguarding agriculture and recreational interests these plans involved for instance the construction of new side channels through the floodplains that increased the discharge capacity of the river and offered space for nature in this context a program called waalweelde was launched by the university of nijmegen in 2006 and adopted by the provincial government in 2008 to connect public private and societal organizations in the planning and implementation phase of river management based on a bottomup approach this integrated multiplayer program aimed to develop a safer more natural and economically stronger riverine landscape unfortunately the integrated approach of the waalweelde program has not been extended to the maintenance of the floodplains which remains sectoral this has resulted in new conflicts increasingly stakeholders recognized that floodplain management had become a very complex dynamic and fragmented issue and that more integrated and collaborative initiatives were needed to achieve sustainable floodplain management in the longterm this recognition led to the establishment of a taskforce floodplain management in october 2011 which aimed to find an integrated multiplayer approach for the maintenance of the newly constructed multifunctional river landscapes an approach that had been very successful in the early planning and implementation phases in their final report the taskforce proposed a new governance structure consisting of a waal board in which different governmental organizations would cooperate and new privateprivate collaborations between land owners and nature conservation organizations called stewardships meanwhile the budgets of the governmental organizations declined and in 2015 one national governmental organization was even abolished completely the government service for land and water management which had 960 full time staff in this study organizations were chosen as node level as in stein et al ingold and knoke et al the selection consisted of seventy organizations that already cooperated in the waalweelde program complemented with knowledge institutions and farmers associations the waalweelde program included organizations based on their position their role in decision process and their reputation the key actors included governmental organizations nongovernmental organizations businesses knowledge institutions and associations of farmers finally the list was checked by the chairman of the waalweelde taskforce floodplain management the respondents were selected on the basis of the following criteria they represent one of the 70 listed organizations they have a high position in their organization such as director or manager with this selection we ensured that respondents could represent the collaborative relations of their organization large organizations were split based on the level of departments or districts respondents were asked by email to fill in a survey about their collaborative relations this email was followed up by a reminder after 2 weeks and a phone call after 3 weeks the survey consisted of an introduction stating the objective and questions on social characteristics such as name and function of the respondent name of the organization scale of activities and involvement or interest in flood protection andor nature finally respondents were asked to select from a list of 70 organizations the organizations with which they interacted and to indicate the strength of their interactions for flood protection and nature objectives separately the respondents could add missing organizations to the list the options given for strength were yearly or less quarterly monthly and on a weekly basis of the 70 initial organizations two did not exist anymore and four replied they were not involved in floodplain management of the remaining 64 organizations 47 filled in the questionnaires which constitutes a response rate of 73 percent seventeen organizations did not respond including seven municipalities seven respondents added in total seventeen organizations however none of these organizations were added by more than one respondent for this reason we assume that the original list of organizations included the most relevant actors social network analysis the survey data were modified before analysis in the software program ucinet three organizations were removed from the data because they indicated no involvement or collaborative interests in either flood protection or nature secondly two respondents filled in the survey for the provincial government therefore one respondent was removed from the data ultimately the data of 43 actors were analyzed regarding collaborative ties for the sna in this paper we used primarily reciprocated collaborative ties meaning that both actors indicated that they collaborated since each tie depends on two actors the data are more robust to reporting errors in case actors indicated different meeting frequencies the lowest frequency was used the data were clustered by creating six groups based on the main organizational task or function these were flood protection the network as a whole actorgroups and individual actors results this section presents the results of the social network analysis first we present and compare the wholenetwork properties of the blue and green networks subsequently we focus on the involvement of the six groups of actors and define the most central players in dutch floodplain management finally we discuss the likely effect of the abolishment of the government service for land and water management network characteristics table 2 presents the social network data describing the wholenetwork properties of the green and the blue networks for all frequencies of collaboration and for monthly and weekly collaboration the blue network for all frequencies consisted of 36 actors with reciprocal ties and the green network of 42 actors even with the higher number of actors the green network is denser by 30 and has a higher degree of centralization both networks have a relatively high crossboundary exchange and all groups are connected to the network which altogether implies a heterogeneous network the density and degree centralization values combined describe how well a network is connected both networks the density metric analyzes the connectedness of the network which is also known as network closure the higher the network density the more potential there is for collective action bodin and crona argue that less dense networks have clearly distinguishable subgroups which could have negative effects on the capacity for collaborative processes among subgroups however a very high network density may decrease the groups effectiveness in collective action because this can lead to homogenization of knowledge which decreases the capacity for solving problems wholenetwork properties degree centralization the general procedure involved in centralization is to look at the differences between the number of ties a node has of the most central point and those of all other points centralization then is the ratio of the actual sum of differences to the maximum possible sum of differences also known as the approach of freeman the degree centralization expresses how tightly the graph is organized around its most central point are well connected when focusing on all collaborative frequencies the shape of the networks tends to a centralized wheel or starlike network based on the high degree centralization scores however the higher degree centralization score of the green network suggests that this network is more centralized when focusing on the two highest tiestrength classes both the blue and green wholenetwork indicators drop this has a large impact on the connectedness of organizations in both networks see for example the huge decrease of total ties additionally twelve organizations drop out of the blue and green network on top of the already disconnected actors especially actors of the research agriculture and special interest group figure 3 also shows the large decrease of collaborative ties between the flood protection and nature group in both networks and the increase of the importance of crd1 the government service for land and water management this actor holds the majority of the weekly reciprocal ties and all remaining ties with the agricultural group in both networks the collaborative ties of the special interest group focus almost completely on organizations in the nature group the organizations with a nature interest stay well connected in the green network in spite of focusing on the more frequent collaborations except probability of an organization being on the shortest path between any two organizations in the network the actor could act as a bridge between other actors who are not connected otherwise which allows the actor to influence the information flows and act as a gatekeeper or mediator these bridging organizations can play an important role in facilitating crossscale interactions in environmental management actor nat10 which got disconnected specifications of the groups involvement when we distinguish between governmental and nongovernmental actors we can clearly see the importance of the former while the number of government actors is smaller they still account for 46 to 75 of all ties flood protection and coordination of spatial planning are core government tasks while nature is more a mixed governmental and nongovernmental responsibility government becomes even more important when low frequency ties are removed almost all groups are well connected to each other when all tie strengths are included however the flood protection and agricultural group show little collaboration between each other in either the blue or the green network in addition fig 2 shows the higher number of collaborative ties between the nature group on the one hand and the coordination and research group on the other in the green network as compared to the blue network table 4 shows the actors grouped by their main tasks in the blue network the actors with interest in flood protection and nature have the highest degree of group exchange focusing on monthly and weekly ties only the group exchange of actors responsible for coordination or spatial planning activities increases at the expense of research institutes and special interest groups the green network shows a different pattern with a high group exchange for the actors of the nature objective and a lower group exchange for flood protection compared to the blue network the actors involved in a coordinating role show a similar increase in group exchange when focusing on the stronger ties representing monthly and weekly collaborations emphasizing their relative importance in the whole network the group density is higher within groups than between groups especially in the green network the coordinating group is an exception here their highest tie density shifts along with the issue at stake so the a b fig the central and influential organizations the most central organizations in the blue and green network have been determined based on their number of reciprocal ties and the amount of incoming ties the major difference between the two is that reciprocal degree shows mutual recognition while the indegree values show the recognition of a collaborative actor by others only in addition the betweenness values for each actor are analyzed to identify bridging organizations the governmental actor crd1 has the highest number of reciprocal and indegree ties and the highest betweenness scores in both networks except for the number of indegree ties in the blue network in which case it holds a third place crd1 is the major broker among the coordinators of spatial planning and between this group and all other groups especially the nature and flood protection group its central position and the bridging role are clearly visible in fig 3 in the blue network the second place based on the number of reciprocal ties is occupied by fld 1 the delta program with 27 reciprocal ties this governmental actor was designated as the most important collaborative organization by the others fld1 is responsible for finding common ground for future flood protection measures to deal with climate change so collaboration between various actors is required but also recognized by the others in the green network the second place is held by nat7 the state forestry service with 24 reciprocal ties also the betweenness value is relatively high which expresses the influential role of the state forestry service supplementary material table sd b the actor fld3 state water agency is by mandate an important actor in river management with important management tasks and regulatory powers it takes second place in terms of the number of indegree ties in both networks which shows that it is recognized by the other actors but the ties are not reciprocal the state water agency itself recognizes only a limited number of actors as collaborators this suggest an unequal relation similarly the water board appears in the top 5 for number of indegree ties in both the blue and green network but not for reciprocal ties they also do not have an important bridging or coordinating function according to their low betweenness scores surprisingly given its mandate the actor nat6 province of gelderland is not in the top 10 of reciprocal ties in both networks it only scores relatively high with respect to indegree ties in the green network possibly because it holds some regulatory powers concerning nature protection discontinuation of the most central actor due to state budget cuts the government service for land and water management has been abolished on 1 march 2015 the effects of removing this governmental actor can be seen by comparing fig 3 which shows the situation until 1 march 2015 with fig 4 in which we have removed crd1 assuming everything else remaining the same all farmers associations and many other organizations will become isolated and in fact drop out of the networks in total six organizations will drop out of the blue network and seven out of the green network the bridging function of crd1 between the flood protection and nature group will be lost especially the blue network will become very fragmented the green network will still be held together by the group with a nature affiliation discussion complexity of collaborative floodplain management in the article two networks for maintaining floodplains were analyzed one with a focus on flood protection and the other on nature in order to increase insight in the complexity of natural resources management and the alleged changed role of government the analysis has shown first that both the blue and green networks are wellconnected and heterogeneous networks with complex structural patterns crossboundary exchange network density and degree centralization are relatively high compared to other studies the relatively high network density improves the potential for collective action and collaboration because wellconnected networks facilitate communication foster mutual trust and help to prevent or manage conflicts sandstro ¨m andcarlsson showed that high tie density promotes jointaction especially when many ties exist between different types of actors the green network has a higher network density than the blue network indicating a greater potential for collective action on nature issues the high ratio of relationships between different types of actors can be observed in both the blue and the green network even for monthly and weekly ties the high density of the networks may also have some adverse effects an actor with too many ties may feel obligated to please all or most of its collaborative partners this may reduce the actors possibilities for action and slow down progress resulting in partnership fatigue moreover a tangle of collaborative ties may reduce transparency and accountability in addition a dense network implies relatively few contacts with outsiders that may have different points of views this may reduce the capability to innovate the dense green network and the role of nature organizations the size of the green and the blue network indicates that mutual recognition of collaborative partners is stronger in the former than in the blue network the organizations not included in the blue network were mostly organizations with a main interest in nature objectives or research institutes with an ecological interest the clustering in groups is supported by the high group density scores within the groups in the blue network three groups play an equally dominant role flood protection nature and coordination actors especially when we focus on weekly and monthly ties the green network is perhaps not surprisingly mostly dominated by the group of nature organizations which collaborate a lot with the coordinating group and research institutes a b fig overall the respondents believed more strongly in the added values of collaborative partnerships for nature objectives than for flood protection objectives reflected in the higher green network density there are several explanations for this the management of the flood protection objectives could be seen as a governmental issue while interest for nature conservation and restoration issues is more spread and recognized by nongovernmental organizations nature organizations need partnerships to reach their objectives whereas water agencies have strong regulatory powers and their own funding nature organizations have much more experience with collaborative processes than water agencies central actors analysis of the most intensive collaborative ties identified the weak relationship between the nature and flood protection organizations as shown by the few weekly and monthly ties between the two groups to our knowledge this has not yet been formally analyzed for floodplain management although the fragmented governance of dutch floodplains is general knowledge in both networks the most central organization based on degree centrality is the government service for land and water management a national governmental organization established for coordination collaboration and implementation of spatial planning ie a bridging organization the central position of cdr1 in both networks makes the organization a perfect candidate to facilitate the idea of publicpublic collaboration unfortunately in the beginning of 2015 this organization was disbanded due to national state budget cuts the second most influential role is designated to the delta program in the blue and the state forestry service in the green network these organizations have much influence on the current collaborative network and could act as bridges between other actors who are not connected otherwise given their betweenness value it is remarkable that the main authorities for nature were not recognized as important collaborative partners they were not even in the top10 the provincial government only recognized a couple of collaborative partners within the green network in addition their recognition by other actors is also relatively low for a main authority their low ranking is probably caused by the recent decentralization of the nature policies from the ministry of economic affairs to the provincial governments in 2014 which was maybe not yet fully recognized by all actors in contrast the wellestablished state water agency was recognized as an important collaborative partner by many others but did not reciprocate this recognition this low ratio of inversus outdegree ties shows the power and independence of the state water agency and also the provincial government they do not need the other organizations to implement their policies and select only a small number of collaborative partners to a lesser extent this also applies to the position of the water boards the consequences of removing a central governmental actor the states discontinuation of the most central governmental organization will most likely have a large impact on the current collaborative structures especially on the flood protection network assuming all else remaining the same both structural integration and inclusiveness will decline farmers associations and spatial planning agencies will become disconnected the number of links between different groups especially the nature and flood protection group will decrease this may not only reduce opportunities for collective action but also make floodplain maintenance less integrated according to lauber et al it may reduce the exchange of ideas decrease the access to funding and reduce the influence of certain stakeholders exchange of ideas through the whole network is hampered by less network cohesion whereas in particular the municipalities and associations of farmers will be disempowered by the loss of the bridging function of cdr1 crd1 no longer brings together diverse goals which will constrain the funding opportunities especially funding for nature which depends on third parties as it is often coupled with other goals implications for the governments role our data indicate that different groups of interest are connected but it also supports the idea that governmental organizations still control and occupy central positions in the network like in united kingdom this challenges the alleged shift from government to governance yes there is a lot of collaboration but there is also still a lot of hierarchical government the question is whether this is necessarily bad and whether it could be different government can play different roles in collaborations government bodies can be an active participant and use its regulatory powers to implement its own policy and reach its own objectives it can coordinate and facilitate like crd1 did and it can stimulate collaboration hierarchically for instance by changing the rules selectively empowering collaborators with fewer resources and threatening to impose regulation if no results are achieved if government takes on the first role and tries to run the show on its own it could frustrate collaboration but if it takes on the second or third role or both it could potentially stimulate collaboration in any case government still is important and most likely will remain so because of the importance of government attempts to improve the maintenance of the dutch floodplains should involve the governmental organizations watson et al argue that there is a greater need to recognize the integration of land and water management at the local scale and to develop appropriate institutional arrangements for both policy making and policy implementation in our case both the green and the blue networks rely on similar collaborative relationships this offers opportunities for integrating the maintenance of flood protection and nature objectives at the local level and to collaboratively develop an appropriate policy for sustainable floodplain management the basic idea is that a collaborative forum of governmental organizations at higher levels can support ontheground efforts of local groups the discontinuation of cdr1 creates an opportunity to simplify and restructure the network to ultimately achieve a better integration of flood protection and nature management in floodplains at the local or regional level a coordinating or facilitating role could be played by the state forestry service mainly based on their central position in both networks however a coordinating or facilitating role demands for an actor with a wide and a more or less neutral perspective on the maintenance issues these requirements seems to fit better with the tasks and function of the provincial government rather than the state forestry service as well to keep the distance between european and national policies and local actors as small as possible another candidate to take on a coordinating role would be the delta program which holds the second and third most central position in respectively the blue and green network the delta program started in 2009 as a collaborative program involving public and private organizations but it is now responsible for a yearly returning program to improve the flood protection levels and ensure fresh water supply in the context of climate change despite their main focus on water and planning they have the capacity to develop an integrated longterm maintenance vision for the floodplains these ideas should be studied more indepth to prove the feasibility in the end there would be one collaborative network concerning floodplain management still it is worth emphasizing that effective collaborative governance requires that governmental organizations do not become too dominant and recognize others as collaborative partners this is an important factor alongside the need for sharing responsibilities and knowledge flexibility building trust and setting up learning environments for collaborative governance in other words collaborative governance cannot be achieved without a change of thinking and acting of the central government and its executive agencies conclusions in sum this study demonstrated the complexity of collaborative relationships based on a case study on the maintenance of the dutch floodplains using a social network approach the complexity was explored by focusing on the networks regarding two conflicting issues flood protection and nature the organizations in both networks are well connected and diverse in terms of goals whereby the nature organizations possess the most collaborative ties the dense green network includes more organizations and collaborative relationships than the blue network this indicates that the potential for collective action is higher in the green network analysis of the most frequent relationships showed that few frequent collaborative ties existed between flood protection and nature groups the most central organization in both networks was crd1 a governmental organization focused on coordinating land and water management this organization had links with many different interest groups and played an important bridging role between the nature and flood protection oriented organizations quite remarkably this organization has been abolished early 2015 due to state budget cuts in a time period where collaboration is framed as a solution removing a central actor from a dense network will have consequences especially in this case assuming all else remaining the same the structural integration of both networks will decrease especially the bridging function of crd1 between the water agencies and nature organizations will be lost additionally groups such as the associations of farmers and municipalities will become disconnected which may decrease their participation in and influence on decision making on the positive side the discontinuation of coordinating governmental actors will give opportunities to simplify and restructure the complex collaborative network for example through a more facilitating role of the provincial government who could support ontheground efforts of local groups in both the blue and green networks governmental actors have the highest number of reciprocal ties and dominate the collaboration the powerful and independent role of the main authorities can be deduced from the differences between the number of incoming and outgoing ties reflecting recognition by others and of others respectively therefore we argue that currently there is no shift from government to governance with respect to the maintenance of the dutch floodplains to achieve more collaborative governance new collaborative relationships have to be developed which requires time effort and recognition of nongovernmental actors as full partners

until recently governmental organizations played a dominant and decisive role in natural resource management however an increasing number of studies indicate that this dominant role is developing towards a more facilitating role as equal partner to improve efficiency and create a leaner state this approach is characterized by complex collaborative relationships between various actors and sectors on multiple levels to understand this complexity in the field of environmental management we conducted a social network analysis of floodplain management in the dutch rhine delta we charted the current interorganizational relationships between 43 organizations involved in flood protection blue network and nature management green network and explored the consequences of abolishing the central actor in these networks the discontinuation of this actor will decrease the connectedness of actors within the blue and green network and may therefore have a large impact on the exchange of ideas and decisionmaking processes furthermore our research shows the dependence of nongovernmental actors on the main governmental organizations it seems that the dutch governmental organizations still have a dominant and controlling role in floodplain management this challenges the alleged shift from a dominant government towards collaborative governance and calls for detailed analysis of actual governance

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introduction as the novel coronavirus pandemic unfolds across the globe the united states has become one of the primary epicenters of the crisis most countries were caught offguard by the seemingly sudden onset of covid19 as well as the rapid transmission rate of the virus many hospitals around the world are at near or exceeding their maximum capacity while the global economy has nearly ground to a halt in the us individuals communities and the social institutions at the core of our society were woefully underprepared for a pandemic at this writing there have been more than 21 million confirmed cases of covid19 and 116000 deaths from the virus in the us the us death toll has now surpassed all other countries and may exceed the number of americans lost in the korean vietnam afghanistan and iraq wars combined disruptions linked to the covid19 pandemic threaten virtually all us social institutions the crisis is highlighting cracks in these institutions by shedding light on systemic vulnerabilities and disparities moreover the increased pressure on some systems is exacerbating long standing flaws and leading to systemic failures for example the crisis threatens to overwhelm the public healthcare system and is revealing significant disparities in the populations access to healthcare the crisis has also placed tremendous strain on financial and economic institutions as national social distancing guidelines and state stayathome orders disrupt business leading to historic levels of unemployment the us corrections system is another institution for which the ramifications of the covid19 pandemic are particularly pronounced the us has the highest incarceration rate in the world at 698 per 100000 residents there are currently more than 23 million individuals incarcerated in the us including approximately 13 million in state prisons 630000 in local jails and 225000 in federal prisons and jails to put these numbers into perspective the us has 5 of the worlds population but a quarter of its prisoners the epidemic of mass incarceration in the us has served to exacerbate the covid19 health pandemic the covid19 pandemic has amplified decades of vulnerabilities disparities and injustices within the us criminal justice system decades of draconian legislation harsh sentencing and mass incarceration have resulted in todays overcrowded prison system these measures have also had a disproportionate impact on minorities and minority communities in particular african americans are overrepresented at virtually all points within the criminal justice system pressure on an already overwhelmed system the spread of the virus poses a particularly serious threat to those involved in our corrections system including prisoners staff their families and the communities in which correctional facilities are located these facilities and communities were particularly underprepared for the sudden outbreak of a highly contagious virus which has resulted in an exceedingly high number of infections among those who work and are held in correctional facilities correctional facilities by their very nature can serve as amplifiers of a highly contagious virus as they are designed to keep a large number of people in close or confined quarters further rampant overcrowding in the us correctional system is likely to exacerbate the spread of an already highly contagious virus for example there is evidence linking cell spatial density to infectious diseases in fact health officials have been warning for more than a decade about the dangers of outbreaks in jails and prisons which are ideal environments for virus outbreaks overcrowded spaces make it practically impossible to implement even the most rudimentary social distancing practices and could turn into a tinderbox for those who work and are held in the system further complicating matters the incarcerated population is aging and exhibits overall high rates of underlying health conditions key factors that have been identified as making individuals more susceptible to being infected and increasing the likelihood of severe symptoms and outcomes including mortality decades of tough sentencing laws and punitive measures have led to a gray wavean aging crisis in our prisons indeed older incarcerated individuals comprise the fastest growing demographic in the us prison system moreover the number of older federal prisoners is growing at a faster rate than the total federal prison population in addition to housing an aging population chronic health conditions are particularly prevalent among incarcerated populations compared to the general population in a study of 759 recently admitted inmates from two new york state prisons 34 were found to have respiratory illnesses these chronic illnesses serve to exacerbate the atrisk status of the incarcerated population since they often mirror those that have been found to be particularly problematic in combination with covid19 it is also imperative to consider the poor level of general hygiene and sanitation practices available in most correctional facilities which are particularly critical in an environment in which social distancing is impractical centers for disease control and prevention recommendations have underscored the value of sanitary conditions in living environments as a practical prevention to contracting the coronavirus unfortunately conditions in prisons and jails do not offer safe environments for inmates or staff in fact americas prisons and jails have long been criticized for unsanitary conditions with some even referring to them as petri dishes further complicating matters the required movement of inmates and staff has made correctional facilities especially risky places conducive to community spread both within and external to the facility while the public perceives prisons as closed environments the virus can enter a facility when a new prisoner is introduced or the virus can travel from visits from family friends attorneys etc in addition to quickly overwhelming the healthcare capacity of the correctional facility a covid19 outbreak in a facility exposes staff to the virus it is exceedingly difficult to contain the virus within the prison complex as prison staff and other service providers return home after their shifts or visits and engage in the community thereby increasing the risk of a virus outbreak in the local community this potentially dire set of interrelated circumstances makes it imperative to implement rapid decarceration measures that effectively balance public safety and public health federal state and local correctional institutions have scrambled to respond to the covid19 crisis in such a way that balances public safety and health while ensuring the safety of prisoners and staff under normal circumstances prisoners being considered for early release are assessed using risk assessment tools that have been rigorously evaluated these tools are implemented at predetermined intervals and there is often a focus on determining the barriers individuals will face upon return to the community as well as the services and resources they will need for successful reentry this process can however be painstakingly slow and is not easily adaptable to a situation such as the current one which necessitates rapid decarceration making matters worse the federal government has issued ambiguous guidance as well as fluctuating and contradictory information concerning what the best course of action is in terms of both protecting against the virus entering a facility and more importantly best practices for preparing for and taking action once the virus is confirmed in a facility by and large most correctional facilities are focusing their efforts on keeping the virus from entering which appears to be a rather futile effort based on recent outbreaks in federal and state facilities another solution many facilities have explored is the development of compassionate release guidelines for inmates who are particularly vulnerable to the virus pose a low risk to public safety andor have not been formally convicted of the offense for which they are being held although there is agreement among most politicians practitioners researchers and laypeople that public safety must be the prime concern thoughtful release policies have the potential to save lives now and offer a chance to explore how massdecarceration might work under different circumstances a few jails that are rapidly decarcerating include charles county maryland los angeles county california and maricopa county arizona each has decreased its jail population by about 30 in two months or less to be sure there are no easy answers as to what the best course of action is when it comes to quickly making decisions on the release of a vast number of inmates even under normal times more than 600000 individuals are released from prisons and jails annually and millions more are already under community supervision moreover many individuals are being released into communities that have excessively high unemployment rates and a scarcity of services that are critical to successful reentry there has been a wide variety of responses across our local state and federal correctional systems arkansas is allowing some covid19 positive staff members who are not presenting with symptoms to continue to work while many other facilities are taking unprecedented measures to stop the spread of the virus colorado and illinois have issued orders refusing to admit new inmates into state prisons and mississippi suspended inperson checkins for those on any form of community supervision although most states continue to test relatively few inmates for the virus some have pushed to test every inmate even those who are asymptomatic such practices led particular units such as the arkansas cummins unit to appear as if they have among the highest rates of infection however it remains unclear if the elevated rate of positive tests is the result of increased spread or widespread testing an unclear federal response as covid19 infections and deaths rose in state and federal prisons jails and detention centers stakeholders citing overcrowding and poor sanitary conditions championed the early release of populations at high risk of contracting the virus the us department of justice has the statutory authority to take measures to mitigate the spread of infection to justice system personnel and federal prisoners the coronavirus aid relief and economic security act gave the doj and the federal bureau of prisons greater authority to release highrisk prisoners to home confinement the first step act increased the availability of compassionate release and the bail reform act has a pretrial release provision in responding to the covid19 pandemic the bop implemented the bop covid19 action plan in addition us attorney general william barr issued memorandas to the bop that provided guidance on how the department should implement its statutory authorities to respond to the crisis including focusing on early release to home confinement for those who met certain conditions the guidance necessitated clear communications in order to be understood and to be effective during the course of an emergency or crisis wellconceived and effectively delivered messages to stakeholders and impacted communities can help ensure public safety and instill public confidence furthermore any messages should be clear and accessible contain specific and adequate information and be coordinated among agencies in assessing bops communications during the covid19 pandemic however stakeholders have described the guidelines and response as lacking transparency on the handling of the crisis and lacking prompt accurate reporting of numbers of those infected and of fatalities concerning the criteria for early release to home confinement stakeholders described it as confusing and conflicting with shifting contradictory criteria on march 13 2020 the bop implemented phase 2 of the bop action plan in phase 2 the bop acknowledged that the us would have more confirmed cases in the coming weeks and noted that the population density of prisons creates a risk of infection and transmission for inmates and staff to ensure continued effective operations and staff safety phase 2 included the immediate suspension of social visits the limitation of legal visits for 30 days screening programs for all newlyarriving persons for exposure risk factors and symptoms quarantining of symptomatic inmates with exposure risk factors and testing and quarantining of symptomatic inmates with exposure risk factors in a march 12 2020 letter to attorney general barr house judiciary committee chairman jerrold nadler requested information on dojs handling of covid19 and the health and safety of those in federal prisons chairman nadler highlighted the risk to vulnerable persons posed by covid19 particularly those with underlying health conditions and requested that the doj consider measures to reduce the number of prisoners in federal custody in a march 19 2020 letter chairman nadler and subcommittee on crime terrorism and homeland security chair karen bass reiterated the need for transparency communication and information on how bop and the us marshals service were handling the covid19 crisis both in protecting employees and individuals held in their custody they suggested the doj consider moving courts to release vulnerable federal prisoners including pregnant women those 50yearsold and older and those who suffer from chronic illnesses they asked that the bop immediately reassess every person with 36 months or less remaining on their sentence to determine if they could serve the last year of their sentence in community corrections and home confinement they requested that the doj use its available authorities including executive clemency commutation furlough compassionate release and parole to reduce the number of federal prisoners and provide prompt and accurate information about the number of covid19 cases and fatalities in bop and usms contract facilities the senate amendment to hr 748 the cares act set aside 100 million in emergency funding for the federal prison systems covid19 response the act signed by president donald j trump on march 27 2020 broadens the dojs authority to expand the cohort of prisoners who can be considered for home release specifically the highrisk and highneed population and under emergency conditions to maximize the time for which the bop is authorized to place a prisoner in home confinement under the first sentence of section 3624 of title 18 us code in normal circumstances the section restricts bops home confinement authority to apply to prisoners who have the shorter of 10 of their term of imprisonment remaining or six months in a march 26 2020 memo attorney general barr noted home confinement as potentially being more effective than imprisonment to protect inmates health and directed the bop to prioritize the use of various statutory authorities to place eligible inmates on home confinement who sought transfer in connection with the ongoing covid19 pandemic eligibility was based upon age and vulnerability criteria in accordance with cdc guidelines and those in low or minimumsecurity facilities could be given priority deemed ineligible would be persons who engaged in violent or gangrelated activity in prison or who incurred a violation within the last year while in bop custody also excluded would be those with a risk assessment score above minimum furthermore individuals would need a demonstrated and verifiable reentry plan that will prevent recidivism and maximize public safety including verification that the conditions under which the inmate would be confined upon release would present a lower risk of contracting covid19 than the inmate would face in his or her bop facility moreover those requesting release to home confinement would require a medical assessment to determine risk factors for severe covid19 and serve a mandatory 14day quarantine period before discharge finally those transferred to home confinement would be subject to location monitoring services and supervised release while the march 26 memo appeared to signal that doj supported widespread early release for high risk populations the elderly those with underlying conditions and those nearing the end of their sentence bops march 31 2020 action plan phase 5 applied a more stringent approach to managing the spread of the virus by further suspending social and legal visits and instituting a 14day lockdown the lockdown included keeping prisoners in assigned cells or quarters and working with the usms to significantly decrease incoming movement to federal prisons in the april 3 2020 memo attorney general barr directed the bop to prioritize early release of prisoners from at least three specific federal institutions fighting major coronavirus outbreaks and to immediately maximize appropriate transfers to home confinement while the guidance appears to give strong directives for early release the step was seen by many as a reactive measure as one stakeholder noted barr wants priority releases of inmates to be from institutions that already are overcome by covid19 for those deemed to be suitable candidates for home confinement under the april 3 memo attorney general barr directed bop to immediately process them for transfer and then immediately transfer them following a 14day quarantine at an appropriate bop facility or in appropriate cases subject to caseby case discretion in the residence to which they would be transferred for home confinement he wrote that bops assessment should be guided by the march 26 memo with the understanding that prisoners with a suitable confinement plan will generally be appropriate candidates for home confinement rather than at institutions in which covid19 is materially affecting operations on april 6 2020 attorney general barr released yet another memo providing guidance to line prosecutors and underscoring that the bra should remain the governing statute for pretrial detention issues he directed doj to not seek detention to the same degree it would under normal circumstancesespecially for those defendants who have not committed serious crimes and who pose a minor risk of flight and who are clearly vulnerable to covid19 doj should continue attorney general barr stated to seek detention for defendants who are charged with serious crimes and who pose a substantial risk of flight or for defendants who would normally warrant detention under the bra and who are not vulnerable to covid19 the april 6 memo left many observers wondering whether attorney general barr had in fact announced a different rule for line prosecutors to apply during covid19 or whether he merely reiterated they were to follow business as usual as directed in the doj memos bop began to place eligible inmates in 14day prerelease quarantine in preparation for their release to home confinement in late april the early release to home confinement for about 200 federal prisoners was suddenly stalled when the doj clarified its earlier guidance to require inmates to have served at least 50 of their sentences in order to be eligible for placement in home confinement in some cases prisoners who had been put into prerelease quarantine anticipating release were suddenly deemed ineligible to be sent home after dojs guidance abruptly shifted to exclude them from release the changing federal guidance has been described as shifting contradictory following criticism the bop again reversed course stating the amount of time served would merely count as a priority factor in decisions the shifting policy caused confusion across prisons and courts attorneys and federal judges demanded that prison officials explain their rules and criteria for releasing inmates during the pandemic and some federal judges resorted to ordering prison officials to define their policy in writing the bop sent a statement to congress expressing regret over the lack of clarity involving inmates with more than half their sentences remaining in a federal prison in butner one of the federal facilities hardest hit by the virus us district court judge alison nathan criticized the bops 14day quarantine program contending that the illogical and kafkaesque quarantine policies put inmates and the community at greater risk of contracting coronavirus judge nathan wrote that the bop policy makes it likely that inmates approved for home confinement will not be released as the virus spreads in the unit the 14day clock will repeatedly restart perpetually prolonging incarceration in addition bops reporting of infections and fatalities has been called into question as being potentially unreliable the american civil liberties union has challenged the accuracy of the bops reporting of covid19 cases in a statement the aclu wrote the recently released numbers highlight one of the reasons jails and prisons across the country comprise 6 of the 10 largest hotspots of covid19 infection putting both those who work and are incarcerated in them at increased risk of contracting this deadly disease we believe that there are likely thousands of additional cases among officers and incarcerated people that havent been reported because of the lack of testing even if the criticism of the bops reporting is correct the numbers reported for both federal inmates as well as bop staff point to the dire need for early release to help mitigate the spread the tool being used by the bop to help determine eligibility for this early release is the prisoner assessment tool targeting estimated risk patterns and needs however significantly pattern was not developed for the purpose of assessing eligibility for release during a public health crisis but rather to assess the recidivism risk of bop inmates the problematics of pattern pattern was created as part of the first step act a federal criminal justice reform bill signed into law in 2018 a key objective of the bill was the reduction of the federal prison population to achieve this pattern would be used to classify inmates as either minimum low medium or high risk for recidivism a prisoner could gain early release based on their score and they could theoretically lower their score during their term of imprisonment by participating in recidivism reduction programming as a means to better address racial inequities often brought by traditional statistical indicators of perceived risk dynamic indicators of conduct within prison would be incorporated into the tools design while the first step act garnered bipartisan support critics have been skeptical of patterns ability to attenuate existing disparities in the criminal justice system based on race and ethnicity further the fact that pattern has yet to be subjected to a rigorous independent evaluation has added to the controversy the use of actuarial risk assessment programs has been argued to produce and reinforce racial disparities in the criminal justice system critics have argued that even when direct indicators of protected group membership such as race and gender are not included as predictors associations between these measures and legitimate predictors can bake in unfairness it has also been argued that even with advances in machine learning the use of proxy variables in algorithms predicting future crime makes it difficult to break cycles of criminalization that are driven by the iatrogenic effects of the criminal justice system itself pattern is not dissimilar to its risk assessment predecessors and has been criticized regarding issues of racial disparity the dojs internal assessment found that only 7 of black offenders would be deemed low risk in contrast to 30 of white offenders to this end the aclu along with other human rights organizations wrote a letter to the director of the national institute of justice asking for an acknowledgement and correction of the racial and gender biases in pattern they further called for the suspension of the program until these adjustments were made and the program was evaluated by independent experts without this they feared pattern threatened to significantly undermine the spirit of the law by indefinitely codifying our criminal legal systems existing racial and ethnic disparities some have furthered this call warning against using the tool as the sole means of establishing who qualifies for compassionate release for covid19 conclusion on march 28 2020 patrick jones who was serving a 27year sentence at fcc oakdale louisiana for a nonviolent drug crime became the first federal inmate to die from covid19 he was 49 years old at this writing there were 85 federal inmate deaths and one bop staff death attributed to the disease simply put covid19 has fundamentally disrupted the us corrections system the pandemic has revealed and exacerbated systemic problems in prisons and jails which were already viewed as amplifiers of infectious disease and are now centers of outbreaks while doj and the bop had to rapidly respond like many agencies and organizations to this extraordinary pandemic the policy guidance issued to respond to the crisis often created confusion for those tasked with implementation unfortunately the poorly communicated policies continue to impact personnel and inmates as such rigorous research in the handling of the covid19 pandemic in us correctional systems specifically related to early release programs would provide valuable insight into necessary policy adjustments to more effectively ensure the health and safety of personnel and inmates research into policies and procedures implemented to contain the spread of the virus in these facilities will have grave consequences for both those behind their walls and those who cycle through them comprehensive pandemic policy and standard guidance that is implemented across the federal corrections system is needed to safeguard essential personnel and inmates due to a myriad of mitigating factors indicators point to a reactive and nonuniform response to early release across the nation because of the selfevident racial and ethnic bias within the us justice system future research should investigate not only the numbers and demographics of those released but also of those not released furthermore because actuarial risk assessment programs have been criticized as playing an exacerbating factor to the levels of disproportionate minority contact with the justice system future independent assessment of the pattern system is a necessity another area in which risk assessment tools may be advanced is by drawing on spatial diagnostic techniques that capture crime risk in the community atlarge current assessment tools disproportionately focus on person level attributes or anecdotal evidence when assessing reentry needs risk of crime measures for the communities in which individuals are returning may allow for a more precise estimate of recidivism risk and better highlight the services and resources necessary for successful reentry the abruptness of release and the lack of time for planning coupled with familiar pitfalls of reentry have led to increased rates of compassionately released inmates ending up homeless in shelters or sleeping in their cars during covid19 this has led to reports of some released prisoners noting that being released due to covid19 has been much more emotionally difficult successful reentry is challenging under normal circumstances and future research would do well to assess the effectiveness of covid19 compassionate release strategies compared to traditional reentry programs rapid decarceration especially when being released into a socially distant and largely halted society is surely not ideal for successful reentry however many more individuals are now being released from detention which will be a critical natural experiment that could inform future reentry programs while the pandemic has created a crisis within the us correctional system it also presents an opportunity to question the utility of mass incarceration and to explore decarceration and the decadeslong toughoncrime laws harsh sentencing and accelerated incarceration which brought about todays era of mass incarceration mass incarceration aging prison populations and high levels of chronic illness all conditions present before the pandemic have merely been exacerbated by it while we should learn from this pandemic and enact policies and procedures to enable our correctional system to better respond to future pandemics we should also take advantage of this time to reduce some of the longstanding issues facing our correctional system

the covid19 pandemic has amplified decades of vulnerabilities disparities and injustices within the us correctional system the spread of the coronavirus poses a particularly serious threat to those that comprise the system including personnel attorneys prisoners their families and extends into the communities in which facilities are located these correctional facilities and communities were especially underprepared for the sudden onset of a highly contagious virus which has resulted in an exceedingly high number of infections among those who work and are held in the facilities rampant overcrowding in the us correctional system an aging population and a population exhibiting high rates of underlying health conditions are highly likely to exacerbate the spread of this highly contagious virus this potentially dire set of interrelated circumstances necessitates rapid decarceration measures that effectively balance public safety and public health unfortunately there has been unclear guidance as well as changing and even contradictory information coming from the federal government concerning rapid measures to mitigate the spread of infection to justice system personnel and federal prisoners in this paper we summarize the federal response and how it has impacted those responsible for implementation furthermore we discuss how systemic deleterious conditions of the us correctional system serve as both accelerants to as well as effects of the pandemic we end highlighting critical issues relating to early release due to covid19 that will necessitate future research

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social media has drastically altered how the world communicates no longer a matter of science fiction large quantities of public and private data can now be exchanged in minutes a recent journal of medical internet research report examined the successes of the youtube channel not just a medical student which attempts to innovatively apply social media for the advancement of medical education 1 as a recently graduated doctor and current undergraduate medical student who regularly use social media for medical education we would like to share our perspectives on this report and future advances within this field medical school curricula often lack teaching on leadership teamwork and innovation all of which could be taught through social media despite saturated curricula these elements are key to health care advancement and of particular importance when undertaking leadership or innovation roles after graduation more broadly the benefits of educational social media are clear by overcoming geographical and time barriers it allows students equal access to teaching and is associated with higher levels of student satisfaction 2 social media platforms have a further advantage over conventional communication methods in that these online spaces are already accessed as part of users daily routines 23 for example it is estimated that 445 of medical trainees and 643 of medical students have active facebook accounts 4 the application of social media to medical education is not without risks professionals and patients alike are susceptible to false information and such content can easily be distributed if time is not taken for validation and peer review these strategies are further important to safeguard the professional reputations of individuals and institutions without considering regulation and the need for a clear distinction between personal and professional opinion public perception of medical practice may be affected and patients could be dissuaded from choosing truly beneficial treatments lack of regulation further permits the spread of biased information such as exaggerated or misleading claims from industries with financial interests finally discussion of real cases risks physicians accidentally sharing personal information and thereby breaching confidentiality a survey of 1600 health science staff and students found that the greatest barriers to educational social media use were concerns about policies and professionalism 3 hence training is required to address these concerns and prevent doctors from becoming liable for damages overall a compromise on speed is warranted to ensure that all content adheres to guidance from regulatory bodies before publication future work should address the lack of quantitative evidence to support claims that social media is an effective educational tool 5 the presently used metrics such as the number of likes shares and comments a post receives require assessment to decipher why exactly an audience deems a video favorable or shareable and research into whether these metrics are indicative of educational value is needed we believe that social media is a powerful tool with the potential to improve medical education and the lives of patients worldwide we thank the not just a medical student team for producing such innovative content and look forward to seeing how this field progresses ©aimee wilkinson james ashcroft originally published in jmir medical education 27112019 this is an openaccess article distributed under the terms of the creative commons attribution license which permits unrestricted use distribution and reproduction in any medium provided the original work first published in jmir medical education is properly cited the complete bibliographic information a link to the original publication on as well as this copyright and license information must be included conflicts of interest none declared

social media has infiltrated almost every sector of life and medical education is no exception as this technology becomes mainstream within society an increasing number of health care students and professionals are using it for learning several important considerations for the risks of this technology are discussed here

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introduction south asians in canada who represent onequarter of the visible minority population and 56 of the entire population 1 are less physically active than white canadians 23 they also have a substantially higher prevalence and incidence of chronic disease and other chronic disease risk factors like lower highdensity lipoprotein cholesterol levels and a higher percentage of body fat 2 according to the population level canadian community health survey 2003 compared with seven other ethnic groups south asians have the lowest prevalence of moderate intensity physical activity 3 various reasons have been documented for low levels of pa among south asian immigrants an overall lack of emphasis on pa and its association with health in south asian culture makes it difficult to adopt an exercise regimen even when advised by doctors 4 prioritizing family time over other activities has also been frequently reported in this community 45 furthermore south asian women also bear a greater responsibility for food preparation and raising children leaving little time or energy for any leisure time pa finally low levels of pa have also been attributed to lack of awareness regarding the duration or intensity of pa that confers a health advantage significant structural barriers like lack of womenonly facilities and provisions for seniors language barriers and lack of confidence in participating in exercise programs 4 6 7 8 9 promoting culturally sensitive pa compatible with the communitys needs is integral to the success of a pa intervention 10 for this an indepth understanding of internal and external motivators personal values and the social context of south asians day to day life is crucial 9 previous studies show immigration status to be associated with physical activity behavior where mostly recent immigrants have been less physically active than older immigrants 1112 currently one of the largest south asian communities in canada exists in the metrovancouver area where the majority of the community members are from the indian province of punjab 13 given our lack of knowledge regarding this communitys attitudes beliefs and conceptualization of pa the aims of this study were to 1 understand how pa is understood perceived and conceptualized and explore social and cultural factors that influence pa behavior 2 investigate how the immigration status intersects with pa behaviors to influence pa levels and 3 engage the community in a discussion about strategies to increase pa in the south asian community methods participants and recruitment participants in this qualitative study were a subset of a larger cohort study recruited from hindu temples and gurdwaras in metrovancouver canada participants in the larger cohort study were south asian adults living in metro vancouver canada with no known previous diagnosis of diabetes able to speak punjabi andor english and identified at an increased risk of diabetes based on the 7item american diabetes association diabetes risk test 14 a subset of 100 participants was recruited for a sevenday study where their pa levels and sedentary time were measured by an accelerometer focus group discussions participants were recruited from the subset of those 100 participants who took part in the accelerometer study we contacted potential participants via phone and explained the purpose of the fgds including their time commitment according to guest et al three to six groups are sufficient to capture 90 of themes in a homogenous study population using a semistructured discussion guide 15 we continued phone calls to elicit participation until a convenience sample of 2030 participants was secured 15 data collection demographic data we include in this study relevant sociodemographic data selfreported by participants in the larger cohort such as age sex years since immigration to canada education level employment status and total household income focus group discussions focus group methodology was selected over individual interviews for its potential to prompt a richer discussion through the interaction between participants 16 fgds were held between may 2019 and november 2019 and lasted from 60 to 90 minutes all fgds were held at gurdwaras and moderated by researcher bm discussions were held in punjabi and were guided by an interview guide based on approximately 8 to 10 questions with additional probing questions some of the questions on the guide aimed to explore how participants conceptualized pa perceived communitycultural or familybased influences in the adoption of a physically active lifestyle how being an immigrant in canada had impacted their pa levels and how pa levels could be increased all participants gave their written and signed consent for this study the discussions were digitally recorded with the permission of all participants approach to inquiry and theoretical frameworks paradigm of naturalistic inquiry this research was guided by the interpretative framework of social constructivism which posits that there are multiple constructions of reality and that ones perspective and experience is central to all definitions of reality 17 within this research we explored pa experiences of south asian immigrants to canada as the immigration experience shapes behaviors and experiences that in turn may impact health behaviors therefore it is important to gain a clear understanding of the shared experiences of this group in order to better understand their pa patterns and observe how cultural norms and immigrant status shape their views and behaviors around pa behavior change models previous studies have used behavior change models to explore personal level influences and intersectoral influences that may impact pa or other health related behaviors in south asians 61819 we applied the social ecological model and the health belief model to our study to understand factors that influence lifestyle behaviors like physical activity these models provided a framework for our fgds question guide under the sem our questions explored the impact of cultural and social influences like gender norms family dynamics support and encouragement from the family to take time out for pa under the health belief model we explored individual level factors like knowledge regarding pa guidelines and attitude and beliefs regarding importance of regular pa and its association with chronic disease we also investigated the effects immigration related stress on pa behavior as well as how immigration had influenced levels of pa social ecological model a social ecological framework identifies key issues related to knowledge attitude and sociocultural and religious factors that may inhibit or facilitate pa among the south asian community according to the sem behavior affects and is affected by multiple levels of influence and individual behavior shapes and is shaped by the social environment 20 this model considers the dynamic interrelations and the complex interplay between individual family and community level factors as well as macrolevel influences such as policy that may directly or indirectly impact health behavior 2122 • what does the term physical activity mean to you • how much physical activity is required to stay fit and healthy • family level factors that may influence physical activity • social and cultural norms that may influence physical activity • factors influencing physical activity levels before and after immigration to canada • community discussions level of awareness regarding physical activity • what can we do as a community to increase physical activity levels health belief model the health belief model provides an explanation of individual level factors in the context of individual level knowledge beliefs and attitudes the core assumption of this model is that individuals will take a healthrelated action if they believe it threatens health and has serious consequences they know that taking an action can avoid that threat and they have control or faith in their abilities to take that action 23 data analysis we applied a directed content analysis which is a reflective nonlinear process and involves identifying and condensing meaning units coding categorizing and creating themes 24 this approach is usually applied when prior research exists about the topic in this case there is a body of literature on conceptualization of pa and perception of barriers and facilitators in adoption of an active lifestyle among south asians 925 hsieh and shannon have developed two strategies for conducting directed qualitative content analysis 26 the first strategy is based on reading textual data and highlighting those parts of the text that appear to be related to the predetermined codes dictated by a theory or prior research findings next the highlighted texts are coded using the predetermined codes for the second strategy the coding process is initiated without primarily highlighting the text in both analysis strategies the qualitative researcher is supposed to return to the text and perform reanalysis after the initial coding process 26 this second strategy provides an opportunity for recognising missing texts related to the predetermined codes and also newly emerged ones it also enhances the trustworthiness of findings 27 based on past literature some key themes were developed to lead the fgds we started with how the participants conceptualized pa what meaning they accorded to the term physical activity what their level of awareness was regarding the pa guidelines and their selfperceived activity levels we then delved into social and cultural influences that are known to impact pa behavior since all our participants were first generation immigrants we also wanted to explore how immigration had affected their pa behavior finally with an intention to engaging our participants in a dialogue about what as a community could be done to increase activity levels we focused on what type of conversations if any about pa were currently taking place within the south asian community and how these could be used to develop effective interventions audio files were transcribed by a team of trained bilingual researchers and coding was conducted by two authors independently in case of a potential conflict in coding the decision was adjudicated by a third coder transcripts were read and reread to obtain an overall sense and an understanding of thoughts and ideas shared using existing theory or prior research we began by identifying key themes or concepts and used these to create initial coding categories as suggested by erlingsson et al and hsieh 2628 two coders independently highlighted the text line by line and condensed the text into smaller parts or meaning units that were further condensed and coded using initial categories in the next step these codes were then grouped under various categories which were then coalesced to form themes 28 any data that did not fall under the original coding categories were identified and analyzed to determine if they were to be classified as a new category 26 a final coding matrix was developed and all data reviewed again and coded based on the final categories and subcategories research objectives were clearly articulated to all participants the consent form clearly outlined research objectives rights and obligations of the participants and the voluntary nature of their participation participants were informed as to how the data will be collected and used for research consent forms were read in punjabienglish as required and all participants were asked to sign if they agreed to participate the clinical research ethics board of the university of british columbia and fraser health research ethics board approved this study results a total of four fgds with 22 participants were held with the first one being all female next two being mixedsex and the last one being all male by our fourth fgd we decided we had reached saturation as the number of new themes dropped significantly and ideas were being repeated demographic characteristics of our fgd sample are presented in table 2 impact of group dynamics dynamics of the focus groups was influenced significantly by the type of group sociocultural factors seemed to influence the nature of engagement and interaction within groups specifically in the allfemale group women appeared to be more vocal in the absence of men to talk about how social and cultural norms restricted their physical mobility and educational attainment thus limiting the realization of their full potential women talked about demanding husbands expecting chefstyle meals their inhibition in joining gyms taking up swimming etc due to fear of being seen in sportswear by south asian community members these views were reinforced by sharing of common experiences as discussed below similarly men may have been more vocal about acknowledging how hard life was for women in canada than they may have been in the presence of women what physical activity means to me our fgds uncovered a range of opinions beliefs and attitudes towards pa among our participants in the absence of an equivalent terminology for physical activity in the punjabi language participants often used the word exercise to describe their understanding of the term walking going to the gym running yoga playing sports like soccer were some of the activities that constituted physical activity most participants understood the overall health benefits of keeping active importance of stepping out in fresh air not being lazy and keep moving even if there is an injury were emphasized or else it was stated diseases like blood pressure diabetes could occur some of the factors that encouraged participants to be active were to keep one free of disease and consequent dependence on medication or other family members benefits of regular pa on mental health and digestive system were also mentioned one female participant in the allfemalegroup had this to say if you are active your mind stays active your health remains good food gets digested well for women being physically active meant doing housework and taking care of grandchildren there was however some disagreementas we can see from the conversation that transpired between two participants whether housework could be considered pa according to one female the cooking that we do thats also exercise when we stir the vegetables and when we are working in the garden we bend have some cultivation at homeor when we kneel to cut grassand all this although is not too much but is exercise nevertheless another female disagreeing with the above had this to say no no nonot this we need to take time out for ourselves decide a place or a spot where you will gofor half an hour or an hour or 20 minutesthats what you should do house cooking or workthat is not exercise i dont believe that is exercise additionally sitting all the time seemed to have a negative connotation and was viewed as being lazy many of our female participants talked about getting diseases if one was lazy and not physically active moreover being too sedentary was in all seriousness considered a risk for developing laziness germs which it was believed would create a never ending cycle of perpetual laziness if you dont exercise and are lazy then all kinds of diseases especially diabetes if we are lazy and keep sitting then we will develop laziness germs and they will weigh us down more we wont be able to wake upwill feel like sitting all the time husband will say you are having teasitting lazy in front of the tv how much physical activity is sufficient we asked the participants about duration and frequency of pa only one out of the six participants in the allfemale group stated that 30 minutes of pa per day was sufficient while the rest believed there was no set time and that housework and taking care of the children kept them busy all day according to one participant fifteen minuteswe do that at leastbarely laughs according to another female participant theres so much to do at home all daycut the grass give water to plants do stuff inside or outside wash the clothes its not that were sitting on the sofa or on the chairs meaning at homeclimb the stairs 10 times and come down the stairs meaning we thats good too the majority of participants in allmale and mixedsex focus groups seemed to have a clearer idea about how much pa was neededat least 30 to 60 minday male participants offered concrete ideas on how to break down prolonged sedentary time at work by taking 5 to 10minute walking breaks to improve circulation as one male participant suggested now see even if you are working two hours and you have 10 minutes even do it then after one hour then do it again for 10 minutes then together you can add it to half an hour while only a few participants were employed occupation related pa was also considered a source of exercise as a female participant talked about the physically intensive job she had where she stands for almost 8 hours and sorts out clothes walking appeared to be the most popular exercise among the participantsespecially those relatively older in age as one male participant stated see dear for 100 health problems theres one treatment meaning among 100 illnesses theres one treatment and that treatment is wholly walking walking is a very good thingits a very wise thing men who were older mostly identified walking to and from the gurdwara every day as a significant source of their pa while the younger men talked about playing sports running and going to the gym one female participant pointed out that going to the gym was even better but this did not seem a popular trend in the south asian community perceived physical activity levels and factors that may influence physical activity when asked about the selfperceived levels of pa the majority of participants believed they were sufficiently active as one female participant stated i do very mucha lot of exercise looking younger than ones age was viewed as being synonymous with physical fitness several participants also believed they were much more active and fit than the younger generations one male participant spoke about how his children who were overweight could not do as much work as him for women since housework kept them busy all day they felt they were sufficiently physically active as one female participant noted i actually in the morning go for a walk for half an hour and for the rest of the time for the childrentheres grandchildrenafter getting them ready then after making them food and feeding them then going and dropping them off at school and then going and giving lunchlike thatthen the whole daythen i need to clean the house and do other work then yes keep moving around the household chores just dont end for women participants realized there were several other factors that influenced ones level of pa such as physiological changes with age stress levels and work demands as a male participant stated the rest depending on your age the work you do activity and exercise are always changing as the body changes along with that time and stress how much workload we have it decreases there is no definite formula a female participant talked about how depression had affected her physical mobility mentally we have to think mentally toohow your mental capacity is yeah yeah depression medications as x was saying sometimes i even have arthritis a depressed person is in pain sometimes one cant even get up during the day so how you feel i am saying somebody motivates you participants who were older mostly talked about health conditions and age restrictions on their ability to be more active demonstrating some stretching exercises they did either in bed early in the morning or while standing up according to one female now that we are in this age we cannot do a whole lot of exercise when we are this old we can walk a littlecan just do light exercise one should exercise according to ones age not putting your body under too much pressure another female mentioning her health condition which negatively affected her physical mobility had this to say my son said to me go for walk go for gym go and gym why you sleep i saidi was very upset right i have a problem in my feet and hands according to south asian women who were older poor weather conditions also seemed to hamper pa levels more so for south asians than people of other ethnic groups people who were older and had breathing issues like asthma were particularly affected by the cold danger of slipping during rainy weather was also a constant risk however apart from the above deterrents there was a general recognition that pa was not prioritized in the south asian community as one female participant admitted but we dont do as much as is requiredis necessary for our healthwe dont do that much she believed it was not so much the extraneous factors to be blamed but had more to do with women themselves and like what they said earliersometimes there is no timebut we need to take time out for ourselves we take time for our children and for other tasks for watching tv and other stuffwell entertainment is also important but for exercise if not too much then at least half an hour if we can take out every day she continued we have driving licenses we also have cars at home we blame others that someone doesnt let us go out i dont feel that everyone has this problem we should go to the gym we should go swimming as well or we should go to some lake and sit and spend time there according to another female participant in the allfemale group the need was to awaken our women make them aware gender roles family dynamics south asian women have been identified as being at a particularly high risk for physical inactivity some participants talked about challenges women faced trying to live up to certain gender norms a female participant who was currently employed identified cooking for her husband as the biggest hurdle towards her low levels of pa for me its my husbands cooking laughs i have to make his lunch if it was not for that i could go anywhere he does not like to eat from outside food of my house cooked by methat is how it should be for him and for that i need two hours for sure for cooking its not that you just do it like this and give itno it should be good perfect food men also seemed to acknowledge that it was tougher for women as one male participant in the allmale group stated for them its a big problem because they now go to work and also do housework for them its a very hard job for them exercise if they need anything it is help another male participant agreeing to the above added especially in these countriesits different in india and pakistan there is a person for washing dishes a person for washing clothes person for cleaning different person for cutting vegetables over here in canada you have to do everything yourself its a hard life for ladies while the majority of the female participants talked about being busy with household chores and childcare they viewed these activities as their biggest source of pa and hence not an obstacle towards being able to take time out for pa as one female participant noted housework instead of being a barrier was actually refreshing yesbut i am able to do all the houseworkwhatever there is well that also refreshes your mindwe go out as wellgoing to the store the mind gets refreshed all our systemwe get energy body feels energized it appeared that there was unwritten expectation that women who were older and living in multigeneration homes would contribute towards taking care of the grand children as one female had this to say and if we are not even going to take care of grandchildren then what else are we going to do women seemed to take pride that they could still manage to take care of the grandchildren and run the housedespite their advanced age as one woman in the allfemale group noted but despite that according to my age i am about 74 exercise is very good but i do a lot of housework too all of iti meanall the kitcheni take care of it we inquired about family influences that may encourage or hinder pa for the most part women who were older reported being encouraged by their children to be active exercise and take time out for themselves according to one female participant i get full supportfrom the children as wellthey say to usthey make a schedule for us and tell us everything like do this you should eat this one male participant talked about how he encouraged his mother and her friends to start walking rather than sitting in the park and talking unlike female participants male participants noted they had no family restrictions or responsibilities that would constrain them from being activeespecially now with the children all grown up some also talked about helping out at home with house chores and stated there should be no shame in helping your wife cultural influences in south asia there is a strong culture of respect towards older people in general including ones parents which is often manifested in serving them at all times as such adult children may unknowingly end up discouraging their elderly parents from performing light pa we probed this question with participants of relatively older age to explore if they had encountered similar situations from their childrendaughterinlaws while none of the participants experienced this a male participant acknowledged that restricting elder parents from working around the house was an expression of respect my mom who is 86 years old she would do work and all of us would get angrythe 6 of usthe 3 brothers and the 3 wiveslike mother you should sit down if someone comes they will say that no one lets the old woman sit my mother would tell us son im not doing this because of you im doing this for my healthi do it for that the day i sit i will remain sitting this is why she did work he also noted that in india they do not let elder parents work because people talk participants agreed with the importance of working well into your old age as one female participant concluded this means that like if we drop everything and say that our sons and daughterinlaws are here now lets sitthis is all wrong as long as you can keep it going keep it going women appeared to have been negatively impacted by some traditional cultural practices which influenced their lifestyle behaviors several female participants attributed low levels of pa in south asian women to the way they were brought up in indiathe overall cultural influences that inhibited young girls from being physically mobile or getting good education in cities as one participant claimed they parents would stop us from everything even the educated ones among the friends would also be afraidthat girls should not do this thingi am telling you the truth she went on to explain how lack of awareness about pa and restrictive cultural and social influences held them back from everything at that time in the cities or village there was no such education telling us we need to stay active we need to live like this girls need to do thatbecause women have always been held back a girl cannot do this a girl cannot do that cannot go there her response to why south asian immigrant women in a country like canada are still not active enough was at that time girls would only do jvd referring to some educational degree at that time i did not get admission close by in schoolcollege my family did not send me farthat we are not going to send her away these things remain in your heart so over here you are so old now have seen everything but still we have to ask our husbands for everything and support them thats a habit now that was developed then south asian culture was also perceived as being inhibitive towards women who wanted to initiate an exercise regimen one female participant had this to say the other thing is that now it is a little bit differentin our community when a woman goes out alone to start doing that is very difficult because in our community people are like huh she goes to the gym now she must be dressing up like that they have not seen her at the gym but you can wear whatever you want to but they will say she is dressing up like white people now modesty and fear of what the community members may think appeared to be a strong factor in discouraging women from accessing gyms and taking up activities like swimmingas one female had this to say if we say we go for a swim then they say she must be wearing swimsuits there must be south asian men there even when we ourselves begin exercise regimen we feel the same way that there will be south asian men and we are wearing such clothes how will it look now i am in burnabyi go i would feel the same way too i got a suit which covered me up till here shows minimum at least this longright with smaller suits i was like there may be someone from our community because i have never been out dressed like this before but once i started going there i felt fine the advantage i had was that over there is that our community people do not go there are noneover here in surrey there are more she also noted that if south asian men were accompanied by their wife it made them feel more comfortable to be in the gym by themselves this was mostly because being with ones wife would make a man less likely to stare or be disrespectful at another south asian woman who was by herself participation in active sports is not very popular among south asian immigrants one male participant talked about how his close friends and neighbors reacted to his interest in marathons upon arriving in canada my friends and pals and the neighboringall around would say why are you taking a risk raise your kids you are in canada raise your kids you will break your leg where will you go your kids will starve and die and i am like why will they die physical activity levelsbefore and after immigration to canada the majority of our participants came from villages in india and were from an agrarian background while men had performed physically intensive work in the fields tilling soil farming and harvesting women other than cooking and household chores also milked buffaloes churned milk and helped in other farm work as one female participant put it we got so tired there now we think it is time for us to rest in this country canada now its our time to rest so lets just sit and rest but we dont know that we are procrastinating pa was woven into the fabric of their life as farmers and there was no need to take extra time out for it as one male participant stated because in india we had to do a lot of physical work like ploughing the fields we did not need to walk or exercise over there we would go to the fields use a kae an iron gadget to cut grass we would hold a kae and cut grasshow was the tummy going to bulgeif anything it would go in because we would use kae water the fields used our hands to cut hay milk buffaloesthere is no need for exercise over thereas our hands arms and legs would be moving upon immigration to canada most participants talked about working in mills while women raised the children the work in the mills was very hard participants talked about life being very stressful as recent immigrants with no time to be more active when first arriving in canada when asked about pa level on arriving as recent immigrants one female participant responded what active we didnt even know about ourselves were so busy we had to get established the families who were left behind us in india from both sides maternal and inlaws we had to get them here too and get them married and get their letters immigration paperwork then our own children another male participant however noted that he became more active upon immigration as back in india he was a student and had to sit and study for long hours since excelling in school was the top priority participants also talked about an overall increase in level of awareness around pa as one male participant noted at that time the mindset was different now the awareness in the media has changed the mindset towards activity is the best way if you want to live several other participants also believed there was a lot of knowledge around a healthy lifestyle as compared to before according to one male participant even if a person these days does not exercise i notice that he is conscious about what he is eating or trying to control thatand other than food their attention is also towards exercising and they are also conscious about after eating how much they need to walk the majority of participants also thought that now they were more active than their peers back home in india according to one female participant no no they friends back in india are not active their daughterinlaws move in and they become dependent upon them participants talked about cheap labor in india and dependence of people on domestic help to cook do household chores and drive even the farmlands according to the participants had now been handed over to contractors and much work in the fields had been mechanized as one female participant noted compared to here canada over there india there is no comparison families over there they will be waiting for the servants to come and make tea for them i was there with my niece for two months and when i would go to the kitchen to do some work she would be like no you sit massi aunt he servant will come and make tea another female participant added nonow at this time ladies my agethey are like now we have blood pressure our knees hurt now we have this health condition they dont do any work before they would be churning milk now there is nothing they do even the ones who are not very financially well off will have at least two helpersone to clean the floors and one to wash clothes comments from many in the group supported the belief that the health of their peers was deteriorating at a faster pace attributing this difference to a sedentary lifestyle according to one female participant i have friends wahi guruwe are all sitting hereone walks with a er what you call it wheelchair walker another poor friendher knees hurt too just like meshe is my age and is sitting one passed away whenever i go all my nieces say you are the healthiest compared to them all my knees have just now started hurting a little but its gurus blessing otherwise i am fine there was a tendency to compare south asians with other ethnic groups and acknowledge some differences that existed regarding lifestyle for instance one female participant who had been raised in malaysia noted that while labor and domestic help was cheap in malaysia too however some of the other ethnic groups that she had lived with did not rely so heavily upon domestic help as people did in india because no but other races are active the chinese other races they also have servants and everything but they are very active illnesses depend on their health they are active withincommunity discussions surrounding physical activity according to our participants there were very few discussions around the importance of being physically active at the community level gurdwaras where the community members met regularly played little role in providing a platform for discussions around health and lifestyle one female participant mentioned a club she attended on a monthly basis where they shared health tips and invited health experts but for the most part as one male participant put it the conversations at most community gatherings were limited to community gossip another male participant however differed with the views above stating that he had noticed a change in awareness from when he first arrived in canada as an immigrant also while growing up in india he noted he had never seen women go out for a walk but now he would see big groups of women going out for a walk together which he believed was a welcome change what can we as a community do to increase our physical activity participants expressed a need for face to face question and answer format with the health care professionals one female participant felt there was a need to educate the community another female participant highlighted the role men can play in promoting pa among women yesraise awareness among the people not just women but men as well as when the men become aware because sometimes they are active they dont have a lot of chores to do at home they come home from work they are idle they go out for women housework totally ties them down they cannot go out and the man knows it too that my wife too needs to stay healthy so he will try and help her get out of the house that help should be therethe women need to be helpedthey need to take out so much time for themselves if no one helps her then she is going to be stuck there she continued with the following advice all in all seminars are very important in which there shouldnt be anything extra said the seminar should discuss food and healthrelated topics dont just give us books to take homewe dont understand themget anything out of them several participants talked about educating and raising awareness in the community about leading an active lifestyle one male participant talked about a weekly dialin radio program on the punjabi channel in the past where a doctor was available to answer any healthrelated questions what doctor tells you vs what you read we dont have time to read the knowledge you get from listeningi get more knowledge from listeningas there is no time to read and listening is easierit makes sense to me what he the doctor tells youyou follow that some participants were of the view that there was no dearth of education everyone understood pretty well as to why it was important to take care of our diet and exercise regularly as one male participant noted there is a lot of awareness here everything is available on the tv and newspapers a lot of programs air a lot now its up to everyone i say everyone should exercise it is a good thing and how ever much one can do they should another male participant in put it this way the media in canada informed us what is happening everything that is when we started to change ourselves my whole life i never ran or exercised no i had not done an activity because bsc science is really hard there in india and when i had come to canada i was 50 years old that is when i i joined our gym thats when i did gym and thats when i started running recent immigrantsat greater risk for sedentary lifestyle and unhealthy diet during the discussions some participants identified newly arriving immigrants and their children from india as a truly highrisk group for sedentary lifestyle and unhealthy dietwhich unlike them came financially better off and with no awareness regarding healthrelated issues as one male participant noted children that are born here they do not like punjabi restaurants eating sweets or other foodsthey do not do so but the main problem is arising from those that are coming from back east the children coming from india and pakistan new immigrants because their parents attend 3 marriage ceremonies a day they attend three marriages and how much they must eat they the children carry this in their genes he continued with the following conclusion so it doesnt matter how much we try to tell them or educate them the genes will be suppressed momentarily but then surface ultimately discussion this study aimed to understand how physical activity was perceived and conceptualized by the south asian community how sociocultural influences and participants immigration status intersect to impact this lifestyle behavior and finally what the community members believe can be done to help the community members become more active we were able to identify some unique often intersecting factors that may help explain low levels of pa among south asians variation in how pa was explained or defined shows each individual had herhis own concept of what pa meant to them and not all of these concepts were congruent with that of health experts similar to other ukbased studies where south asian women attributed most of their activity to housework and childcare 629 our female participants also shared this view however many of these chores do not meet the definition of moderate intensity pa and thus may explain the incongruence between selfreported and accelerometermeasured moderate to vigorous pa levels in some mixedmethods studies 629 this demonstrates that women did not understand mvpa intensities similar to other studies with relatively older participants 430 age and other comorbidities played a predominant role in what type of activity participants could engage in some older participants talked about being limited by weak bones asthma that became worse in the cold painful knees and fear of falling while performing paespecially in the rain a few women who were older and claimed they were sufficiently active demonstrated some of the exercises they did every morning some before getting out of bed and others standing in the kitchen while cooking but these were mostly stretches and did not meet the required intensity level to be considered moderate pa although the majority of the participants were generally aware of the overall health benefits of regular pa understanding of the actual levelsintensity of pa required to gain health benefits was limited while lpa has its advantages this finding also reported in other studies 62931 underscores the importance of clearly communicating the concept of activity intensity to this group so that they know what activities qualify as moderately intensive and will yield health benefits for instance vacuuming washing windows sweeping thoroughly are some of the household activities that have been shown to be conducted at moderate intensity 32 however since converting sedentary time into lpa seems to be a more achievable goal the health benefits conferred by lpa should not be underestimated studies have found an association between lpa and more beneficial plasma lipid profile as well as lower postprandial glucose and insulin levels in overweightobese adults 3334 additionally health promotion programs need to tailor their interventions to the specific pa needs of different agegroups as there seems to be a gap regarding knowledge of what types of exercises can be safely performed by older people unlike other studies 29 for the most part the women in our sample did not frequently label housework as a barrier as it was also viewed as their single biggest source of pa of which they took pride in however it is important to remember that most women in our study were older and retired and housework was not as intensive for them as it may be for younger women who may be working full time and also running the household and tending to family demands a relatively younger woman who was also employed identified cooking demands as the biggest barriers to her taking up any pa while the majority of participants were able to quantify the amount of pa required on a daily basis and believed there was an adequate level of community awareness for being active our allfemale group was unable to state how much activity was recommended on a daily basis this demonstrates that women who are older may not be cognizant of the amount of pa that would positively impact health which may partly account for low pa levels additionally keeping in mind the physical limitations of older age as mentioned by many participants the emphasis needs to be on moving more as suggested by canadian 24hour movement guidelines for adults aged 65 and above according to which lpa including standing and lowering overall sedentary time also matters 35 while some participants talked about and demonstrated some stretching exercises which they said helped them with stiff joints there was no conversation around resistance training and balance activitiesespecially pertinent for older participants who also talked about fear of losing balance and falling while exercising this may be either because these topics were not brought up for discussion like some other issues deliberately touched upon in our conversations or because the participants lacked knowledge about benefits of these exercises this is something that needs to be further explored in future research low levels of pa seem to be partly explained by some social and cultural factors consistent with other studies 36 some participants reported that a greater emphasis on excelling in school discouraged participation in sports and related activities from early childhood fear of injury was noted as an additional deterrent this is an indication of not only an overall low uptake of organized sports in the community as observed by previous research 3738 but also of unfounded fears around organized sports causing irreparable body harm thus incapacitating one to take care of hisher family some genderbased restrictions also emerged during our discussions female participants talked about a reluctance to take up any regular pa regimen at the gym for the fear of being seen wearing activeswim wear and being labeled as becoming too westernized modesty as a concern has been observed by previous research too where it was mostly muslim women from relatively more conservative backgrounds who talked about feeling uncomfortable wearing western sportswear 6730 our findings underscore the need for providing access to older south asian women of all religious denominations either allwomen facilities or spaces within facilities which are restricted to women only there is growing evidence on the positive effects of pa on mental health 39 40 41 as reported in other studies participants recognized the positive impact of pa on mental health however in our study more female than male participants reported how depression and stress had reduced their desire to engage in any activity south asian women have been observed to be at a higher risk for depression resulting from social isolation 42 postmigration factors like loss of social status social support separation from family difficulty integrating into a new culture and lack of employment puts immigrants at a particularly high risk for stress and depression first generation south asian immigrants seem to be at a higher risk for untreated depression and stress given the stigma of mental health conditions within south asian populations 43 a study of older adult south asians in calgary found more than double the prevalence rate of mild depression compared to the national average 44 the issue of stress among south asian immigrants is poorly researched 7 and more understanding is required around how mental health affects health trajectories including adoption of lifestyle behaviors like pa furthermore it is important to be aware of the competing priorities and complex challenges that recent immigrants face in trying to settle and integrate into the canadian system as this has a direct impact on their mental health and thus it is within this context that health intervention strategies should be identified in india health education is typically delivered by a doctor answering questions posed by community members not surprisingly this method of health communication is what the majority of our participants described as the optimal approach involving the target community in developing culturally appropriate interventions appears to be important in their acceptability delivery and uptake 4546 due consideration to the communitys preferred model of communication and learning has also been observed to improve intervention uptake 47 this study highlights the need to tailor professionalled health interventions to meet the specific needs and preferences of the communityspecifically regarding choice of an effective mode of communication of health messages our participants were especially concerned about the current generation of recent immigrants who were not used to physically intensive work like their ancestors and had little knowledge regarding what constituted a healthy lifestyle and advised that this was the group that needed to be targeted by health practitioners indeed a higher proportion of recent immigrants from visible minorities are inactive compared to established immigrants 114849 and this underscores the need for targeting this highrisk group additionally the role of gurdwaras in becoming a platform for health was also raised as an option for health education communication participants believed gurdwaras had a great potential to influence community thinking and needed to play a more substantial role in community health a recent study examined the feasibility acceptability and effectiveness of a mosquebased pa program for south asian muslim women in canada apart from concluding the mosquebased program to be feasible and acceptable at the end of the intervention there was also a significant increase in selfefficacy scores and fewer women were classified as inactive 50 similar gurdwaratemplebased pa interventions targeting south asians in the usa have also been highly effective 51 52 53 collaborating with faithbased organizations with a captive audience thus has considerable potential and can be a financially viable avenue for health promotion campaigns strengths and limitations the study provides some unique insights into south asians views attitudes and beliefs towards pa holding at least two samesex focus groups had a clear benefit as both women and men talked about issues we feel they would not have felt comfortable discussing openly in the presence of the opposite sex however some limitations apply related to inadequate representation of the subgroups within the south asian diaspora and thus findings need to be interpreted with caution as they cannot be applied to all south asians also as we were not able to touch upon sedentary time and its conceptualization among the south asian community we recommend that future studies explore this phenomenon adequately especially considering the relatively high sedentary time accumulated by the participants in our accelerometerbased study 54 conclusion and implications for policy and research findings from our study highlight the importance of considering social cultural and structural contexts when exploring possible behavior change interventions for south asian immigrants similar to other studies our data shows a strong presence of collectivists influences like the family unit and the wider south asian community and migrationrelated challenges 5556 the recognition of which is important in developing and implementing successful health promotion programs additionally it is important to recognize that this ethnic group is not homogenous as can be seen from diverse and sometimes conflicting findings from similar studies 57 thus cautioning health promoters against the danger of stereotyping the ethnic group there are variations within the community members of experience and perspective regarding pa as noted by other studies and these experiences and perspectives are not static as these vary according to heterogeneity within ethnic groups based on for example acculturation geography socioeconomic status age and gender 45 these factors need to be considered for developing tailored highly effective health promotion interventions data cannot be shared with anyone outside of the project team as consent was not taken from the participants for this the ethics approval committee can be approached with data requests and they can provide options for sharing study data the ethics review committee of the data curation bushra mahmood formal analysis bushra mahmood

south asian immigrants in western countries are at a high risk for metabolic syndrome and associated chronic disease while a physically active lifestyle is crucial in decreasing this risk physical activity pa levels among this group remain low the objectives of this study were to explore social and cultural factors that influence pa behavior investigate how immigration process intersects with pa behaviors to influence pa levels and to engage community in a discussion about what can be done to increase pa in the south asian communityfor this qualitative study we conducted four focus group discussions fgds among a subset of participants who were part of a larger study fgd data was coded and analysed using directed content analysis to identify key categoriesparticipants expressed a range of opinions attitudes and beliefs about pa most believed they were sufficiently active women talked about restrictive social and cultural norms that discouraged uptake of exercise postimmigration levels of pa were low due to change in type of work and added responsibilities

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introduction adolescence is considered a crucial phase of individual development and transition encompassing physiological psychosocial and cognitive transformations that often manifest as various psychological disorders 1 among these mental health issues anxiety and depression have emerged as the most prevalent afflictions affecting adolescents 2 anxiety is frequently characterized by an excessive response to challenging or unpredictable situations including obsessivecompulsive tendencies worry tension and panic 3 conversely depression represents a condition of persistent and pronounced sadness 4 these two psychological disorders tend to exhibit similar traits and frequently cooccur with approximately 85 of individuals with depression also experiencing significant anxiety symptoms and 90 of those with anxiety disorders simultaneously presenting depressive symptoms 5 studies have revealed that globally around 34 of adolescents aged 1019 years are at risk of clinical depression with a particularly elevated risk among asian adolescents 6 another study encompassing adolescent populations in 82 countries indicated a global overall prevalence of anxiety among adolescents to be 9 the persistence of depressive and anxious symptoms in adolescents can profoundly disrupt their developmental process and lead to considerable detriment in their social relationships and physical wellbeing 7 notably during the covid19 pandemic a quarter of adolescents worldwide experienced heightened depressive symptoms while onefifth grappled with significantly deeper anxiety symptoms the pandemic exacerbated anxiety and depression in adolescents compared to previous reports from largescale adolescent cohorts 8 a metaanalysis conducted in china demonstrated that the covid19 pandemic notably impacted the mental health of over onefifth of middle and high school students revealing a higher prevalence of depressive and anxiety symptoms compared to studies not involving covid19 9 however it is important to note that the prevalence of anxiety and depression varies significantly across countries as a result researchers have encouraged the adoption of socioculturally specific strategies and tools such as focusing on family relationships to effectively prevent anxiety and depression problems 6 the family functioning as an ecosystem assumes a highly significant role in the development of adolescent mental health by acting as a protective buffer against adverse mental health problems and reducing the risk of such issues arising 10 from a sociological standpoint family functioning profoundly influences the physical and mental wellbeing of individuals families that exhibit healthier functioning tend to offer greater emotional and material support to their members assisting them in coping more effectively with negative conflicts 11 olsons circumplex model of marital and family systems highlight family communication as the primary facilitating dimension for enhancing family cohesion and flexibility both of which contribute significantly to the psychological wellbeing of family members 12 family communication defined as the exchange of information ideas thoughts and emotions among family members 13 serves as a pivotal bridge in transmitting emotions within the family and significantly influences the development of adolescent mental health 14 positive family communication is characterized by the ability of family members to comprehend trust and attentively listen to one another while negative family communication typically involves an inability to engage in calm dialogues and express emotions and ideas effectively leóndelbarco and his colleagues underscored the pivotal role of the family environment in adolescent development emphasizing that communication styles and behavioral patterns within the family exert a profound impact on adolescent mental health 15 moreover family systems theory posits that problems among family members can often be traced back to miscommunication within the family unit 16 negative family communication such as family conflict and reduced frequency of communication can erode family relationships lead to unhealthy family behaviors and contribute to adolescent anxiety and depression 17 conversely studies have demonstrated that positive parentadolescent communication fosters a stronger bond between adolescents and their parents promoting family cohesion and resilience which serves as a crucial protective factor against adolescent depression 18 despite geçer and yıldırıms empirical study suggesting a direct impact of family communication in adults on psychological distress in the context of covid19 19 very few studies have specifically investigated the influence of family communication on adolescents psychological problems of anxiety and depression furthermore there is a dearth of research exploring the mechanistic relationship between family communication and psychological disorders in light of the covid19 impact both parents and adolescents in china have been compelled to curtail their activities outside the home resulting in prolonged close interactions with their family members 20 in this context the significance of family communication becomes even more prominent and its impact on adolescents mental wellbeing assumes greater importance therefore this paper aims to explore the relationship between family communication and adolescents anxiety and depression in the context of covid19 as well as the mechanisms that influence this relationship adolescents exposed to family violence are at an increased risk of experiencing depression and anxiety family violence refers to the mental and physical abuse endured by an individual from other family members 2122 research has demonstrated that adolescents living in environments with parental family violence are more susceptible to depression compared to those not exposed to such family violence 23 furthermore exposure to family violence not only heightens the likelihood of depression in adolescents but also leads to adverse physiological responses such as elevated blood pressure as a consequence of the depression 24 prolonged exposure to family violence during childhood particularly from mothers is associated with elevated psychological problems such as depression and anxiety during adolescence 25 according to the global status report on violence against children 2020 jointly published by the world health organization and the united nations childrens fund approximately one in two children between the ages of 2 and 17 years worldwide experiences some form of violence each year nearly 300 million children between the ages of 2 and 4 years are regularly subjected to violent discipline by their caregivers 26 while authoritative statistics on family violence against adolescents in china are not available data from reputable chinese media indicates that almost 45 of parents have resorted to family violence against their children primarily in the form of verbal abuse and on average a child experiences family violence once a month 27 these statistics underscore the frequency of adolescents exposure to family violence the behavioral family systems model posits that communication skills play a vital role in family functioning reducing family conflict promoting positive family relationships and enhancing adolescents resilience in coping with stress 28 olsons circumplex model of marital and family systems has consistently revealed that family communication fosters family cohesion and resilience as supported by a wealth of empirical studies 29 30 31 furthermore high levels of family cohesion and resilience have been associated with decreased exposure to family abuse 32 therefore it is reasonable to infer that family communication acts as a protective factor for adolescents against family violence and consequently alleviates psychological problems such as anxiety and depression especially during the covid19 pandemic when family members have had more frequent interactions the potential for the occurrence of family violence has increased 33 subsequently elevating the likelihood of adolescents experiencing anxiety and depression 34 more explicitly we can hypothesize that family communications mitigating effect on anxiety and depression in adolescents is achieved through its role in reducing family violence problematic internet use emerges as a significant contributing factor to the heightened risk of depression and anxiety in adolescents this issue shares behavioral characteristics akin to drug addiction alcoholism and gambling addiction and exerts adverse effects on an individuals social relationships as well as their physical and mental wellbeing 35 numerous studies have substantiated the association between problematic internet use and adverse mental health outcomes for instance a crosssectional study by li et al demonstrated a direct increase in the risk of depression among chinese middle school students due to problematic internet use 36 adolescents exhibiting problematic internet use displayed significantly poorer mental and emotional states compared to their counterparts without such behaviors 37 particularly during the covid19 pandemic the correlation between problematic internet use and adolescent anxiety and depressive symptoms became evident with related studies highlighting the direct impact of problematic internet use on anxiety and depression 38 the detrimental impact of problematic internet use on adolescent mental health can be attributed to the tendency for excessive internet engagement to reduce realworld social interactions among adolescents 39 as they spend more time in the virtual world they may have less interaction with their friends and family in real life this substitution of virtual socialization for real socialization may exacerbate symptoms of anxiety and depression however it is noteworthy that chinese adolescents internet use is often regulated by their parents making the family a crucial influence on adolescents problematic internet use nielsen favez and rigters literature review on parenting family factors and adolescents problematic internet use highlighted that positive family parenting and family dynamics were associated with lower problematic internet use while negative parenting and family dynamics were linked to higher rates of problematic internet use 40 when parents maintain a positive communication relationship with their children such as actively listening and understanding their thoughts it typically reduces adolescents problematic internet use 41 similarly positive family environments such as increased family expression have been shown to reduce adolescents problematic internet use and time spent online 42 family systems theory posits that individual and family members behaviors are influenced by the patterns of family relationships which can have an intergenerational transfer effect 43 for instance individuals in families with healthier communication patterns are more likely to develop healthy interpersonal relationship patterns in the future conversely unhealthy communication within the family may lead to problematic interpersonal relationships or even conflict and violence in the future in summary we propose that adolescents problematic internet use likely serves as a mediator of the effect of family communication on their anxiety and depression positive family communication can help reduce adolescents problematic internet use consequently lowering their risk of anxiety and depression furthermore when family communication is positive there is a corresponding reduction in family conflict and violence which may also play a significant role in reducing adolescents problematic internet use in this paper we aim to investigate the relationship between adolescent family communication and anxiety and depression as well as explore the potential mediating roles of family violence and problematic internet use we propose the following research hypotheses and present the research model diagram see fig methods participants and procedure the data used in this study comes from the 2022 china population psychological and behavioral survey the survey was carried out from june 20 to august 31 2022 in 148 cities 202 counties 390 townsstreets and 780 communitiesvillages across 23 provinces 5 autonomous regions and 4 municipalities directly under the central government in china 44 a large number of investigators were recruited and rigorously trained nationwide for the survey respondents were invited to respond facetoface and oneonone through an electronic questionnaire participants will be asked to sign an informed consent form before responding a total of 31480 questionnaires were distributed and 30505 valid questionnaires were finally collected resulting in an effective rate of 969 for this study adolescents aged 1218 years were selected from the data and after excluding the samples with illogical answers such as who are currently enrolled in a masters or doctoral program a total of 2711 valid samples were obtained the sample screening process is shown in fig 2 this study has been officially registered with the china clinical trials registry and has been approved by the clinical research ethics committee of the second xiangya hospital of central south university of all 2711 samples 1601 were female 1742 were high school and below 1960 lived in urban areas and 438 had a per capita monthly household income of more than 9000 fig 1 research hypotheses model diagram measures general characteristics the general characteristics of the participants were collected including gender age residence education level and monthly per capita household income family communication the assessment of family communication was carried out using the family communication scale developed by olson et al this scale consists of 10 items designed to evaluate the quality of communication among family members from the individuals perspective as well as the communication skills and abilities of family members sample items include family members are satisfied with the way they communicate with each other family members are able to have calm discussions about issues and family members receive honest responses when they ask each other questions participants rated their responses on a fivepoint likert scale where 1 indicates strong disagreement and 5 represents strong agreement a higher total score indicates a higher quality of family communication during the data analysis phase we randomly divided the 10 questionnaire items into 3 factors to enhance the model fit family violence to measure the violence experienced by adolescents from family members a fiveitem family violence scale was developed comprising two dimensions mental violence and physical violence the mental violence dimension includes three items my family does not care about me when i am in a bad state my family invades my privacy by going through my cell phone dictates what i wear and restricts my interpersonal interactions my family compares me to others and openly accuses me causing me embarrassment and undermining my selfconfidence the physical violence dimension consists of two items my family has physically harmed me using direct blows or objects my family has engaged in unwanted physical contact with me participants rated their responses on a fivepoint likert scale where 1 indicates almost never 2 denotes sometimes and 3 stands for often the total score was calculated by summing the scores of the five question items with higher scores indicating a higher level of exposure to family violence in this study the cronbachs α of the family violence scale was 0901 indicating good internal consistency moreover the results of the confirmatory factor analysis demonstrated that the scale exhibited high reliability as evidenced by the following fit indices comparative fit index 0932 normed fit index 0931 goodness of fit index 0910 incremental fit index 0932 and standardized root mean square residual 0046 problematic internet use this study employed the problematic internet use questionnaire short form developed by opakunle et al 45 to measure problematic internet use the scale comprises three dimensions obsession neglect and control with a total of six question items two for each dimension for instance have you ever experienced feelings of worry moodiness or tension when not online but once you are online these feelings disappear do you feel nervous irritable or stressed if you are unable to go online when you want to participants provided responses to each question item using a 5point likert scale ranging from 1 never to 5 all the time higher scores on the scale indicate a higher degree of problematic internet use suggesting a stronger association with internetrelated issues and potential negative consequences anxiety the 7item generalized anxiety disorder scale was developed by spitzer et al 46 and has gained widespread usage in clinical settings and various studies particularly for screening anxiety disorders the gad7 comprises seven items that assess symptoms of generalized anxiety such as feeling tense anxious or on edge and not being able to stop or control worrying participants were asked to rate how often they experienced these symptoms in the past two weeks based on their feelings the scale was rated on a fourpoint scale with responses ranging from 0 not at all to 3 almost every day higher scores on the scale indicate a higher level of anxiety severity during the data analysis phase the 7 question items of the scale were randomly divided into 3 factors to enhance the fit of the model making it more suitable for the studys purposes depression depression was measured using the wellestablished 9item depression screening scale known as the patient health questionnaire this selfrating scale is a simple yet effective tool for screening individuals for depression and is widely used internationally with translations available in multiple languages 4748 the phq9 comprises nine common symptoms associated with depression such as feeling down depressed or hopeless and having little interest or pleasure in doing things participants were asked to rate how often they experienced these symptoms in the past two weeks based on their feelings responses were recorded on a fourpoint scale with options ranging from 0 not at all to 3 almost every day higher scores on the scale indicate a higher level of depression severity during the data analysis phase the 9 question items of the scale were randomly grouped into 3 factors to enhance the model fit making it more suitable for the studys analytical purposes statistical analysis the data were analyzed using spss 250 and amos 250 with twotailed pvalues at the 005 level considered statistically significant descriptive statistics such as mean standard deviation and sample size were computed using spss 250 scale reliability and validity tests path analysis and mediation tests were conducted using amos 250 to test the hypothesized mediation models a structural equation model with asymptotically distributionfree estimation was employed the analysis assessed direct indirect and total effects through 2000 bootstrapped samples to ensure robustness and accuracy of the results effect estimates and biascorrected 95 confidence intervals were calculated to provide a comprehensive understanding of the relationships between the variables under investigation results scale reliability and validity tests reliability and convergent validity tests of scales in this paper all dimensions of all scales were analyzed by cfa and the results showed that all factor loadings met the criteria recommended by joreskog and sorbom of greater than 045 and significant 49 further the component reliabilities were all greater than or equal to 07 while the mean variance extractions ranged from 0906 to 0968 which meets the discriminant criteria proposed by fornell and larcker 50 and chin 51 ie the composite reliability value should be greater than 07 the ave value should be no less than 05 and the factor loadings for each question item should be greater than 05 therefore the five scales presented high reliability and convergent validity reliability and convergent validity tests of scales in this study the ave method proposed by fornell and larcker was used to test the discriminant validity of the variables 50 the ave method means that the average variance extracted for each dimension must be greater than the squared value of the correlation coefficients between the dimensions and the dimensions but since the ave is a squared value it must be converted into the same squared unit if it is to be compared with the pearson correlation between the dimensions therefore the ave value is generally rooted and then compared and if it is higher than the value of the interdimension pearson correlation the dimension can be claimed to have differential validity in this study the ave values are in bold diagonal and all ave values are greater than the standardized correlation coefficients under the diagonal therefore we consider the validity of the distinction between the study variables to be good overall model fit analysis this study uses the model fitting criterion recommended by hu and bentler 52 including χ 2 df 3 goodness of fit ≥ 095 adjust goodness of fit ≥ 095 tucker lewis index of ≥ 095 comparative fit index normed fit index ≥ 095 root mean square error of first of all since the dependent variables depression and anxiety have strong correlation while their relationships and difference are not the focus of this study therefore we established a correlation between them in the model fitting stage in order to improve the overall model fitting effect secondly when the sample size is larger than 1000 and does not conform to a positivetrait distribution brownes recommendation of asymptotically distributionfree model estimation can be used 53 thirdly since the sample size of this study reaches 2711 the model chisquare value will result in a significant pvalue due to the large sample size and make the sample fit poorly to the model matrix therefore we used the bootstraps method proposed by bollen and stine to correct the model fit indicators 54 the chisquare value obtained after the bollenstine p correction analysis was 18462 while the original model had a chisquare value of 75453 so all other fitness metrics needed to be recalculated then the calculated fitness metrics show that the model of this study has a good fit indicating that the model of adolescent family communication and mental health constructed by the sample of this study can be used to explain the actual observed data and the fit results are presented in table 3 path testing for structural equation model regarding the path analysis for the structural equation model family communication was significantly and negatively related to family violence problematic internet use depression and anxiety with moderate or small effect sizes in contrast family violence exhibited significant and positive relations with problematic internet use depression and anxiety with moderate or small effect sizes furthermore problematic internet use was significantly and positively related to depression and anxiety with moderate effect sizes the results were presented in table 4 and fig 3 mediating role analysis indirect effects among family communication depression and anxiety were analyzed by performing a bootstrap with 2000 resamples and a biascorrected and percentile confidence interval of 95 as is shown in table 5 four indirect effects were significant among family communication depression and anxiety family violence mediated the relationships between family communication and depression and between family communication and anxiety chain indirect effects between family communication and depression or anxiety via family violence and then through problematic internet use were also found in the present study besides the proportional values of indirectonly mediated effects of the four is 6530 6651 3864 and 4242 the model explained 4621 of the participants anxiety and 336 of the participants depression however the mediating role of problematic internet use in the relationship between family communication and anxiety and depression was not significant as a result h4 was supported while h3 was not discussion this study focused on anxiety and depression among chinese adolescents during the covid19 context and utilized structural equation modeling to examine the relationship between family communication and adolescents anxiety and depression additionally the study explored the potential mediating roles of family the results of the study revealed a significant negative correlation between family communication and adolescents anxiety and depression indicating that positive family communication can effectively reduce adolescents psychological distress moreover family violence was found to mediate the relationship between family communication and anxiety and depression suggesting that family violence may play a crucial role in influencing the association between family communication and adolescent mental health contrary to hypothesis h3 problematic internet use did not mediate the relationship between family communication and anxiety and depression however the study confirmed the presence of a common chain mediating role involving both family violence and problematic internet use linking them to the impact of family communication on adolescent anxiety and depression overall the findings of the study support hypotheses h1 h2 and h4 and provide valuable insights into the factors influencing adolescent mental health problems these findings have significant implications for understanding the role of family communication and violence in adolescents mental wellbeing offering useful directions for family communication and violence interventions aimed at improving the mental health of adolescents positive family communication can reduce the risk of anxiety and depression in adolescents based on the results of this study it was found that positive family communication plays a significant role in reducing the risk of anxiety and depression in adolescents this suggests that adolescents who experience a more positive and open family communication environment are less likely to suffer from severe anxiety and depression these findings align with a study conducted by zhou et al 55 which also demonstrated that adopting positive and conversationoriented family communication can prevent adolescents risk of depression bowens family systems theory proposes that each family operates within an emotional system where emotional connections among family members are interconnected positive family communication involves the free flow of information empathic understanding between parents and children clear and accurate messaging consistent parenting and satisfying interactions 56 such positive communication fosters a sense of security controllability and predictability in adolescents lives leading to a reduction in negative emotions 5758 on the other hand unhealthy family communication characterized by negativity and avoidance can contribute to increased stress in adolescents school and personal lives thereby increasing their vulnerability to anxiety and depression 57 it is essential to highlight the significance of family communication especially during the covid19 pandemic when adolescents are exposed to vast amounts of information related to illness and risk these changes in information processing and learning patterns can easily impact their mental health leading to issues like anxiety and depression 59 family communication becomes a crucial means of coping with uncertainty during such challenging times active communication with parents allows adolescents to obtain accurate information about the epidemic reducing their perception of future uncertainty and risk and alleviating adverse emotions 60 family violence mediates the relationship between family communication and anxiety and depression another significant research discovery pertains to the mediating role of family violence between family communication and adolescents anxiety and depression this suggests that fostering positive family communication may assist adolescents in avoiding victimization from family members thereby reducing their susceptibility to anxiety and depression jiménezs study 57 62 conversationoriented family communication typically enhances adolescents mental health whereas conformityoriented family communication conversely exhibits a negative correlation with adolescents mental wellbeing 63 in china family education often follows an authoritative approach leading to a higher likelihood of adolescents becoming victims of family violence especially from parents 64 authoritarian family upbringing usually involves less emotional support and more criticism and behavioral control 65 resulting in strained parentchild relationships and an increased risk of depression 66 the context of covid19 has significantly increased the occurrence of family violence 67 this is due to the elevated risk factors brought about by covid family violence and problematic internet use as chain mediators between family communication and the relationship between anxiety and depression the findings suggest that while problematic internet use does not directly act as a mediating mechanism between family communication and anxiety and depression family violence and problematic internet use function as cochain mediators in this relationship this novel contribution to existing literature highlights the role of problematic internet use as a consequence of family violence which in turn influences adolescent anxiety and depression specifically we observed that inadequate family communication may result in mental or physical violence from family members leading to an increase in problematic internet use among adolescents ultimately exacerbating their mental health issues this phenomenon can be elucidated through the lenses of selfregulation theory and approachavoidance theory according to selfregulation theory individuals tend to employ specific strategies to regulate and manage their emotional and psychological states 69 when adolescents face violence from family members they may lack healthy and positive emotion regulation strategies such as seeking social support expressing emotions or actively problemsolving consequently problematic internet use becomes a seemingly simple and instant escape enabling them to temporarily alleviate their discomfort without addressing the underlying problem additionally approachavoidance theory suggests that individuals may respond in an avoidance or coping manner when confronted with stressful events given that the adolescent population is mentally immature and possesses limited coping skills they may be more inclined to adopt an avoidance response 70 in the context of covid19 external avoidance approaches may be less accessible to adolescents leading them to turn to the internet as their primary means of venting and regulating their internal emotions nevertheless this escape may further intensify their negative psychological emotions 38 however it is essential to acknowledge that the relationship between adolescents family relationships and mental health is complex and contradictory necessitating further research to delve deeper into how family relationships family violence and problematic internet use impact adolescents mental wellbeing particularly in the context of covid19 changes in family and online environments may have a more intricate influence on adolescents mental health calling for more indepth exploration and understanding of this domain limitations and implications the studys limitations warrant consideration firstly the crosssectional design employed restricts the establishment of causal relationships between family communication and anxiety and depression future research should adopt a longitudinal design to ascertain the directionality of these associations secondly the study solely focused on family communication as a family factor to gain a more comprehensive understanding future research should incorporate other factors like family satisfaction parental mental health and family socioeconomic status thirdly the study exclusively included adolescents necessitating future research to encompass a broader sample group to better comprehend the impact of family violence lastly the study solely concentrated on family violence and problematic internet use as mediators overlooking other potential mechanisms future research should explore additional social school family and individual factors beyond the studys scope despite these limitations the studys results carry significant practical implications it stands as one of the few inquiries delving into the mechanisms underlying the relationship between family communication family violence problematic internet use anxiety and depression the findings underscore the significance of family communication and family violence in influencing problematic behaviors and psychological wellbeing among adolescents emphasizing the necessity to enhance adolescents communication skills with their parents and reduce the incidence of family violence furthermore while previous studies have mainly investigated the effects of family relationships on perpetrators this study fills an important gap by shedding light on the psychological and behavioral manifestations experienced by adolescent victims of family violence from their perspective conclusion this study sheds light on the connections between family communication family violence and problematic internet use in relation to adolescent anxiety and depression providing valuable insights into their underlying mechanisms particularly positive family communication exhibits a negative association with adolescent anxiety and depression indicating that fostering healthy family communication can mitigate negative psychological symptoms in adolescents furthermore family violence acts as a mediator between family communication and anxiety and depression underscoring the potential of improving family communication to prevent adolescents from becoming victims of family violence and indirectly reduce their vulnerability to anxiety and depression additionally the study reveals a cochainmediated effect of family violence and problematic internet use on the relationship between family communication and anxiety and depression suggesting that adolescents may employ problematic internet use as a coping mechanism for dealing with the negative emotions stemming from family violence consequently enhancing family communication skills emerges as a significant approach to alleviate adolescents anxiety and depression consequently reducing the prevalence of family violence and problematic internet use these findings carry significant implications for families educational institutions and society at large in the endeavor to help adolescents alleviate anxiety and depressive symptoms a strong emphasis should be placed on the importance of family communication promoting understanding and support among family members through positive communication concurrently proactive measures should be taken to prevent and intervene in family violence safeguarding the physical and mental wellbeing of adolescents moreover attention should be given to adolescents problematic internet use guiding them in the proper utilization of internet resources and discouraging excessive reliance on virtual socialization as this can contribute to a reduction in their anxiety and depression levels competing interests the authors declare no competing interests • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from

objective the objective of this study is to explore the relationship between family communication family violence problematic internet use anxiety and depression and validate their potential mediating rolethe study population consisted of chinese adolescents aged 12 to 18 years and a crosssectional survey was conducted in 2022 structural equation models were constructed using amos 250 software to examine the factors that influence adolescent anxiety and depression and the mediating effects of problematic internet use and family violencethe results indicate that family communication was significantly and negatively related to family violence β 494 p 0001 problematic internet use β 056 p 05 depression β 076 p 01 and anxiety β 071 p 05 and the finds also indicate that family violence mediated the relationships between family communication and depression β 143 ci 198 080 and between family communication and anxiety β 141 ci 198 074 chain indirect effects between family communication and depression β 051 ci 081 030 or anxiety β 046 ci 080 043 via family violence and then through problematic internet use were also found in the present study conclusions in conclusion positive family communication is crucial in reducing anxiety and depression in adolescents moreover problematic internet use and family violence mediate the effects of positive family communication on anxiety and depression therefore improving family communication and promoting interventions aimed at reducing family violence and problematic internet use can help reduce anxiety and depression in adolescents thus promoting their healthy development

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background eliminating health disparities and increasing the quality and years of healthy life for all people is a global goal to achieve these identifying and addressing the health needs of populations that are often overlooked need to be prioritised refugees as people living in highly stressful situation are particularly vulnerable to mental illhealth as a result of the trauma experienced preand postmigration 1 2 3 although literature abounds on the mental health disparities of refugees and nonrefugees in many regions of the world the lack of information on refugee communities in west africa is notable 4 in a metaanalysis of preand postmigration factors associated with mental illhealth among refugees only two of the 59 independent comparisons of refugee and nonrefugee populations in adults from the same lowincome country were compared and none was from africa 5 although africans constitute only 12 per cent of the global population 6 about a quarter of the worlds 88 million refugees are in africa 150000 of whom live in west africa 6 apart from the trauma which drove many into exile post migration factors have also been linked to the excess burden of mental health problems borne by refugees 7 therefore increasing attention is now being drawn to the conditions in which refugees live in exile and the longterm mental health of refugees in exile the mental health status of refugees in subsaharan africa is of particular interest because of the poorer quality of life of the region compared to other regions of the world 8 the qol though subjective as an indicator of wellbeing has been shown to be inextricably associated with the mental health status 13 it is yet to be documented if refugees in host communities with similar culture and living conditions fare better than those in richer countries the added dimension of the community quality of life which is the perception of being belonging and becoming a part of the community in which one lives may also have consequences for mental morbidity 3 the research questions in focus in the present study are do disparities exist in the mental health status of refugees and nonrefugee populations in nigeria would the qol and cqol also differ and would such disparities be sufficient to threaten the mental wellbeing of refugees in excess of the nonrefugee population this study aimed at providing communitybased comparative assessment data on the mental health status and its interaction with the qol and cqol of refugees who have been long term residents in oruijebu south west nigeria compared with the nonrefugee population the studys hypothesis was there is no difference in the mental health and qol of refugees and nonrefugees in southwest nigeria methods study area this study was conducted in oruijebu ogun state southwestern nigeria oruijebu which borders agoiwoye a university town is a semiurban town which according to the 2006 census had a population of 27000 9 the oru refugee camp is located on the outskirts about 500 m to oru town the camp which is the only one in the country was established in october 1990 as an initiative of the united nations high commissioner for refugees with the approval of the federal government of nigeria and in collaboration with the nigerian red cross society 910 the camp was established as an aftermath of the liberian civil war in 1989 and many of the refugees have been resident in the camp since then nationalities represented in the camp included liberians sierraleoneans and togolese health and social welfare benefits were withdrawn and the camp was officially closed in 2007 in order to encourage voluntary repatriation of the refugees many of the refugees however chose to remain in the camp there are about 5000 refugees currently living in the camp majority of whom are liberians the camp is made up of 11 residential blocks consisting of 72 houses of two bedroom units many other makeshift mud houses have been constructed by the refugees over the years there is a nonfunctional mini clinic and one primary school of eight classrooms some of the refugees were involved in vocations like hairdressing trading transportation using motorcycles teaching and clerical work within and outside the camp study population the study population comprised of male and female residents of oru community and the refugee camp aged 18 years and above who have resided in the area for at least one year prior to the study ethical approval for this study was obtained from the university of ibadanuniversity college hospital institutional review committee before study was commenced written informed consent was also obtained from participants before administering questionnaires a crosssectional study design was used comparing refugees with nonrefugees within the same geographical location the minimum sample size estimated to compare the proportions with poor mental health status was based on a prior estimate of 22 for poor mental health 11 an expected difference of 15 was used at 95 confidence interval 80 power and 15 precision this was adjusted by a factor of two for clustering effect and allowance was made for 10 nonresponse a sample size of 431 per group was thus estimated a cluster sampling technique was used to obtain a representative sample of the refugee and nonrefugee communities adults aged 18 years and above were selected from the oru community and the refugee camp for the nonrefugees four enumeration areas were chosen by balloting from the 60 enumeration areas in oruijebu each enumeration area had 1530 houses with about 511 adults per house all eligible adults in each enumeration area were interviewed for the refugees eight residential blocks were selected by balloting from the 11 blocks in the refugee camp all eligible respondents in the 10 houses present in each selected block were interviewed study instruments intervieweradministered structured questionnaires consisting of the miniinternational neuropsychiatric interview 12 who quality of life 13 and the community quality of life adapted from the florida mapp field guide 14 were used for data collection the cronbachs alphas were 086 093 and 093 respectively the assessment of clinical variables such as suicide ideation visual hallucination drug and alcohol abuse mania posttraumatic stress disorder obsession and depression was done using respondents responses to specific questions on the mini measures quality of life the world health organization qualityoflife group defined healthrelated quality of life as the individuals subjective evaluation of disease and impairment and disabilities 13 the quality of life was measured with the whoqolbref with 26 questions which were measured on a 5 point likert scale scores were scaled in a positive direction and summed the whoqolbref was developed to be applicable in diverse cultural settings and was designed across several countries including one in subsaharan africa 15 mental health defined as a state of wellbeing in which every individual realizes his or her own potential can cope with the normal stresses of life can work productively and fruitfully and is able to make a contribution to her or his community 16 mental health was assessed using the miniinternational neuropsychiatric interview mini has been used in a similar environment and validated in nigeria the interrater reliability was 086 17 the mini consists of 26 questions with yes or no responses yes was scored one and no zero scores were summed and score ≤ 5 were labeled as green zone scores 68 fell into the yellow zone and scores 924 fell in the red zone these three zones were dichotomised for the purpose of logistic regression analysis the green zone and the red ie a combination of the yellow and red zones 1318 community quality of life is the assessment of the quality of life within a communityunderstanding a community from the members point of view 19 community qol was assessed using the community qol questionnaire the instrument consisted of 12 questions which elicits responses through a likert scale 14 each participants score was summed disability defined as any impairment that can make performing an everyday task more difficult disability and physical illness were assessed through selfreport data analysis data was collected in august 2010 and analyzed with spss version 17 the mean scores for the qol and cqol were compared with the student ttest the determinants of mental health status and qol were explored using logistic regression analyses the 2log likelihood value was used to assess what model had the best fit results are presented as odds ratios with 95 confidence limits results sociodemographic characteristics of respondents response rate was 989 consisting of 444 refugees and 527 nonrefugees the mean length of stay of refugees in the camp was 86 ± 48 years table 1 shows the sociodemographic characteristics of respondents the refugees were slightly older with a mean age of 348 ± 128 years versus 333 ± 81 years for the nonrefugee population the sex distribution was not significantly different while the majority 376 of the refugees were married most 468 of the native population were not significantly higher proportion of refugees had polygamous marriages lived in poorer type of accommodation and had no formal education compared to the nonrefugees the occupations of both populations did not differ significantly ethnicity of indigenes and the nationality of refugees twothirds 292 of the refugees were liberians other nationalities represented were sierraleoneans 143 and togolese 3 of the nonrefugees majority 427 were of yoruba ethnicity health status by respondent status table 2 shows health status by respondent category a significantly higher proportion of nonrefugee respondents reported physical disability like chronic back pain and joint pain 159 versus 84 there was however no statistically significant difference between refugees 151 and nonrefugees 209 who reported current health problems disparities in the quality of life and cqol profile of respondents the qol profile of respondents based on scores from the whoqolbref is shown in table 3 the mean qol scores for each of the four domains examined were significantly lower for the refugees the overall qol and cqol scores were both significantly lower for the refugees mental health disparities figure 1 shows the reported symptoms of mental illhealth as assessed by the mini the most commonly reported symptoms among the refugees was depression p 005 followed by obsession p 005 post traumatic stress disorder p 005 and mania suicidal ideation was the least reported p 005 whereas auditory hallucination visual hallucination and alcohol abuse were commoner among the refugee population mental health profile of respondents table 4 shows the mental health profile of respondents a significantly higher proportion of the refugees 275 were in the red zone compared to the nonrefugees 183 predictors of poor mental health status among respondents the predictors of poor mental health following logistic regression analysis are presented in table 5 refugees were three times more likely than nonrefugees to have poor mental health being currently ill tripled the odds of mental ill health unskilled workers skilled workers and the unemployed had two or more times the odds of poor mental health compared to professionals the determinants of poor mental health among refugees are shown in table 6 being engaged in unskilled occupations significantly increased the likelihood of poor mental health the likelihood of poor mental health decreased by 09 for each rise in qol score the factors associated with poor mental health among the non refugee population are shown in table 7 risk factors were increasing age male gender current illness being religious poorer qol scores higher cqol scores and employment as an unskilled or skilled worker discussion after an average stay of about a decade in exile there persisted marked disparities between the mental health status of refugees and nonrefugees in nigeria these findings correspond to those of previous studies of refugee and nonrefugee populations 72021 the finding that the nonrefugee population is very highly educated could be due to the proximity of the study area to a university town thus a good number of the residents of oruijebu are university students and workers the high prevalence of manic symptoms obsessive compulsive symptoms depression and post traumatic stress disorder among refugees in excess of indigenes has also been documented 616 22 23 24 although the prevalence of psychiatric symptoms in this study was higher than previously reported in the country 25 they are however similar to reports from developed countries 2627 the reason for this observation is unclear though it may be due to differences in methodologies as mini is a screening tool designed particularly for the use of nonspecialised interviewers 122829 disparities also emerged in the qol and cqol across all domains this replicates findings among refugee populations in the usa and sweden 30 31 32 the observed disparity in mental health status persisted after adjusting for qol cqol and sociodemographic variables while better qol emerged as protective as seen in other studies 1330 33 34 35 36 increasing cqol scores appeared to increase the probability for mental health problems this is at variance from what has been previously documented 21137 the explanation for this is not clear but might be indicative of a sense of collective social suffering however the marginal increased probability of mental ill health precludes firm conclusions and warrants further evaluation physical health status marital status and employment status emerged as important covariates for all respondents the impact of poor physical health and lower occupational status on both refugee and indigenous study groups is consistent with reports from other authors 34 38 39 40 within group evaluation revealed that the influence of qol on both populations was comparable although the adverse impact of higher cqol scores on mental health was restricted to the nonrefugee population unlike the refugees many other factors such as increasing age male gender and being religious affected the mental health of the native population an overlap in the mental and physical functions was also evident among the native population the risk factors for the indigenous population were similar to the findings of a previous nigerian study 34 surprisingly nonrefugees reported more physical disability compared with the refugees a possible explanation for this observation could be the healthy workers bias 41 42 43 refugees could in fact be healthier than the native population for them to have survived long distances from their countries of origin under adverse conditions whereas more disabled nonrefugees are not able to move and leave their countries this observation could also be due to sample selection bias 4445 unlike other reports 5 acculturative stressors were not associated with greater mental symptoms among refugees neither was the number of years since resettlement the major threats to the mental health of the refugees were the qol and occupational status these factors however had even less impact than they did on the nonrefugee population the singular factor to which mental health disparity could be ascribed was therefore in being a refugee this could be a combination of preand postmigration trauma which leaves a lasting mark that persists even after decades in exile while little can be done to alter refugees premigration experiences public policies can affect many postmigration experiences in order to mitigate the negative health consequences associated with resettlement results of this study point to the need for continued attention to not only the healthcare needs but the welfare housing employment and overall quality of life to support the longterm mental health of refugees and nonrefugee populations alike limitations the crosssectional nature of the survey did not allow for inferences to be drawn as to causal relationship among variables also the selfreported nature of the data means they were subjective although participants own view is necessary the question arises whether it is sufficient 4647 the refugee population is also a very peculiar one with all its support taken away thus the possibility of a selection bias in this study it is however important to note that the majority of refugees in this camp did not take up the option of repatriation to their country of initial origin the refugee study population was therefore similar in age gender and country of origin to the original camp profile furthermore the nonrefugee population might not be very representative of the wider nigerian society as more than half of the samples are very highly educated despite these limitations the study provides unique insights into the mental health and quality of life of refugees and nigerians in oruijebu which is useful in planning community health services conclusions the major factors associated with poor mental health among the refugees were the qol and occupational status these factors however had even less impact than they did on the native population thus being a refugee seems to be the most important factor to which mental health disparity could be associated results of this study point to the need for continued attention to not only the healthcare needs but the welfare housing employment and overall quality of life to support the longterm mental health of refugees and nonrefugee populations alike competing interests the authors declare that they have no competing interests

background refugees as people living in highly stressful situation are particularly vulnerable to mental illhealth as a result of the trauma experienced preand postmigration the lack of information on the mental health disparities of refugees and nonrefugees in west africa is what this study aimed to bridge a crosssectional study design was employed using a cluster sampling technique intervieweradministered structured questionnaires consisting of the miniinternational neuropsychiatric interview mini who quality of life whoqolbref and the community quality of life cqol were used for data collection data were analyzed with spss version 17 logistic regression analysis was used to determine the predictors of mental health status and qol results respondents consisted of 444 457 refugees and 527 543 nonrefugees twothirds 292 66 of the refugees were liberians mean age refugees 348 ± 128 years versus nonrefugees 333 ± 81 years p 005 while the majority 376 847 of the refugees were married most 468 888 of the native population were not p 0001 significantly higher proportion of refugees had polygamous marriages lived in poorer type of accommodation and had no formal education compared to the nonrefugees p 005 the overall qol and cqol scores were both significantly lower for the refugees p 0001 refugees were three times more likely than nonrefugees to have poor mental health or 343 95 ci 183640 overall being currently ill tripled the odds of mental ill health or 273 95 ci 198377 unskilled workers or 278 95 ci 168460 skilled workers or 298 95 ci 203438 and the unemployed or 194 95 ci 129292 had two or more times the odds of poor mental health compared to professionals conclusions qol and occupational status were the major threats to the mental health of the refugees results of this study point to the need for continued attention to not only the healthcare needs but the welfare housing employment and overall qol to support the longterm mental health of refugees and nonrefugee populations alike

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introduction food allergy and atopic dermatitis are significant pediatric health problems in many developed countries the prevalence of these conditions has been increasing over the past two decades in western societies however there is a lack of epidemiological data for bulgaria purpose to study the frequency of different manifestations of doctordiagnosed allergies among families with atopy in bulgaria materials and methods a crosssectional study was conducted among 2408 families with mothers of childbearing age hospitalized between 2017 and 2019 in the maternity ward of st anna hospital varna bulgaria a direct individual questionnaire was applied to obtain information on socialdemographic characteristics and manifestations of various forms of allergies data was analyzed with spss v 210 results the relative proportion of families with evidence of allergy on the side of the mother father or child was 1163 the incidence of allergic diseases among mothers was 605 among fathers 386 and among children 578 rhinconjunctivitis was the leading allergic manifestation in mothers and fathers and atopic dermatitis was the most common manifestation of allergy in their child a significant relationship was established between atopic dermatitis in the family and the overall incidence of allergies in the child conclusions the data resulting from our study may serve as a basis for further research so the mechanisms of atopy to be investigated better prevention strategies need to be developed to address the march of allergy characterized by the initial manifestation of allergy in childhood with atopic dermatitis and moving to food and respiratory manifestations key messages the incidence of allergies has been increasing in recent years both in the world and in bulgaria rhe development of preventive measures to reduce the risk of allergic diseases could be of great importance for public health background in some highincome contexts the covid19 pandemic was associated with improved birth outcomes which was hypothesised to be caused by a positive effect of the pandemic on maternal health conversely an improvement in birth outcomes may have been driven by pandemicinduced compositional changes in parental characteristics which are associated with health outcomes at birth research on this consequence of the covid19 pandemic is critical for understanding pandemicinduced changes in population health and planning of public service provision methods we analysed populationwide data on birth outcomes and parental sociodemographic characteristics from finland collected between january 2015 and december 2021 the total effect of pandemicinduced compositional changes on birth weight and preterm birth rate was estimated by segmented regression models using three conception cohorts a conceived prior to may 2019 b conceived between june 2019 and february 2020 and c conceived during the pandemic between march 2020 and february 2021 preliminary results adjusting for secular trends and seasonality and accounting for inutero exposure to the pandemic the estimated effect of parental compositional change on average birth weight was 365 grams background the attitudes that underlie vaccine hesitancy are important for predicting individuals vaccination behaviour but also for

infection with fever and cough being the most prevalent in addition one parent was tested at the school and was also diagnosed with influenza b indicating the spread of the virus within the community gaps were identified in the scope of public health including the lack of outbreak response protocols and an effective communication network with schools in order to address these shortcomings it is intended to develop action protocols for outbreak scenarios in the school environment and establish a closer response between public health services and the school community the innovative approach of the albufeira phu can serve as a model for other settings and countrieseffective collaboration between healthcare providers and schools is essential to mitigate the impact of infectious disease outbreaks in the school environment the development and implementation of outbreak response protocols is critical to ensure a coordinated response to infectious disease outbreaks

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the foundations for lifespan health begin in the prenatal environment for lowincome and ethnic minority women the prenatal period can be associated with a number of physical emotional social and financial stressors stressful experiences have negative implications for mothers wellbeing but can also have deleterious consequences for fetal and infant development prenatal stress can be conceptualized as a teratogen a factor that can directly affect the developing fetus and is capable of interfering with normal development effects of prenatal stress have been documented on a wide range of infant outcomes including low birth weight preterm birth dysregulated neurobiological activity and behavioral emotional and neurodevelopmental disturbances the impact of prenatal stress can persist into childhood adolescence and adulthood the development of infant physiological stress response systems represents a potential mechanism linking prenatal exposures to infant health and developmental outcomes the hypothalamicpituitaryadrenocortical axis a primary mediator of the stress response regulates the production and release of the glucocorticoid hormone cortisol scholars investigating associations between maternal stress and infant birth health and developmental outcomes have described a fetal programming hypothesis wherein high stress during pregnancy results in an adverse intrauterine environment that can negatively impact infant growth and contribute to a variety of negative health effects across the lifespan in part prenatal stress may affect fetal development via stressrelated activation of the maternal hpa axis resulting in transmission of cortisol across the placenta high maternal stress and resulting excess fetal cortisol exposure is believed to disrupt the normal adaptive function of coregulatory maternal stress systems that support healthy fetal development interference in the normal development of the hpa axis may disrupt subsequent capacities for physiological and behavioral regulation o connor et al reported that higher cortisol exposure in utero was associated with dysregulated cortisol reactivity in infancy deleterious effects on birth outcomes represent a potential mechanism through which prenatal stress may be linked to hpa regulation and later infant health and developmental outcomes although evidence for such a pathway is limited reynolds outlined a theoretical model in which low birth weight mediates the effects of maternal distress on child hpa dysregulation which in turn increases the risk of obesity and metabolic disorders later in life a fairly consistent literature identifies prenatal stress depression and anxiety as risk factors for preterm birth and low birth weight however the role of birth outcomes in the relation of prenatal stress to infant hpa axis activity is less clear field et al reported that low birth weight and prematurity did not explain the poorer neonatal outcomes observed in infants exposed to maternal prenatal depression the impact of prenatal stress may be accentuated in lowincome mexican or mexican american families hispanic women commonly face stressors such as discrimination occupational barriers language barriers and deportation fears compared to caucasian families hispanic families are more than twice as likely to live below the poverty level and considerable research documents deleterious effects of poverty on birth outcomes child stress physiology and child health and developmental outcomes however despite high traditional risk factors hispanic immigrant women tend to have more positive birth outcomes compared to african american and other ethnic minority groups in the us and comparable or lower risk for low birth weight compared to nonhispanic white groups better than expected birth outcomes may reflect a healthy migrant effect which posits that health benefits are due to better mental and physical health of those who choose to emigrate compared to those who stay alternatively the latina paradox hypothesizes that latinas in the us experience protective cultural factors that promote resilience in the presence of stressful conditions potentially translating into better birth outcomes powerful culturespecific values such as strong family and kinship ties and a high value placed on the maternal role may provide protective emotional and practical support for pregnant latina women support from a romantic partner or spouse is a particularly salient protective factor for pregnant women for lowincome mexican american women strong cultural values relating to the family may enhance the protective effects of support during pregnancy further partner support during pregnancy may promote subsequent infant wellbeing more perceived support from a partner has been associated with reduced emotional distress among mothers and distress to novelty among their six to eight week infants with regards to infant cortisol existing studies have predominantly focused on postpartum partner support with relatively consistent findings that partner relationship functioning can significantly affect child cortisol many of these studies have been limited by crosssectional designs that preclude the ability to determine the directionality of influence dipietro notes a number of related methodological issues in the inference of causality in research on the implications of maternal stress for infant outcomes these issues include a reliance on subjective maternal reports for both predictor and outcome shared genetic contributions and potential confounding by other prenatal and postnatal exposures and behaviors for example despite being unique psychological constructs maternal depression and stress are generally significantly correlated creating a challenge to empirically separate their effects further effects of prenatal stress are difficult to disentangle from effects due to stress in the postpartum environment in short while intriguing evidence supports hypothesized causal effects of prenatal stress and support on infant development longitudinal research beginning in the prenatal period that addresses potential confounding factors is needed to better understand the transmission of risk and protective influences from mother to infant existing literature points to negative influences of prenatal stress and positive influences of support on infant health and developmental outcomes but little is known about the extent to which partner support may buffer the impact of stress on infant outcomes particularly in ethnic minority populations the present study investigates the interactive impact of prenatal stress and partner support on infant salivary cortisol reactivity in mexican american women and infants due to the extremely lowincome of our sample we focused attention on economic hardship as our measure of prenatal stress or the stress experienced by mothers when available resources are not adequate for appraised needs such a measure recognizes that objective indicators of poverty such as family income do not adequately capture the psychological sense of disparity at the heart of stress we hypothesized that higher prenatal support from the spouseromantic partner would buffer the impact of economic stress on infant cortisol reactivity at six weeks postpartum such that higher prenatal stress would predict elevated cortisol only for infants whose mothers also reported lower partner support we also examined potential confounding factors such as maternal postpartum cortisol reactivity prenatal and postpartum maternal depressive symptoms and postpartum partner support finally we explored birth outcomes as a potential intermediate pathway linking prenatal stress and support to infant cortisol reactivity method participants participants included 220 women and their infants data were collected at two time points prenatal and six weeks postpartum women were recruited from a hospitalbased prenatal clinic that serves lowincome women from the surrounding community eligibility criteria included 1 selfidentification as mexican or mexican american fluency in english or spanish age 18 or older lowincome status and no prenatal evidence of a serious infant health or developmental problem demographic characteristics are displayed in table 1 recruitment and retention during prenatal care appointments women were approached by a female bilingual interviewer who explained the study and assessed eligibility of women who were eligible 56 agreed to a home visit between 2638 weeks gestation during which informed consent was obtained of the 263 women who consented to the study at the prenatal visit 254 completed a six week visit the current analyses only include those who reported being married or in a romantic relationship at the prenatal visit procedure all interviews were conducted at participants homes in their choice of spanish or english due to variability in literacy survey questions were read aloud to all participants women were given visual aids with written and graphic descriptions of item response formats the 6week interview was scheduled within one week of the infants chronological age of six weeks but for infants born at less than 37 weeks gestation 1 the interview was conducted at six weeks corrected age at the six week interview salivary cortisol samples were collected from mothers and infants before and after videorecorded motherinfant interaction tasks that began approximately 30 minutes after arrival in the home to aid in sample retention interviews were scheduled at the mothers convenience the first cortisol was collected between 830 am and 5 pm the total duration of the home visits was approximately 2 hours women were compensated 75 and small gifts at the prenatal interview and 50 and small gifts at the six week interview measures partner supportat the prenatal visit women completed measures assessing two components of partner support prenatal relationship satisfactionemotional support and expectations for tangible and emotional support after the birth first a seven item version of the dyadic adjustment scale measured womens satisfaction in their relationships and emotional support from their spouseromantic partner previous research supports the validity of the das for hispanic americans sample items include in general how often do you think things between you and your partner are going well and how often do you confide in your partner one 1 one infant was born at 26 weeks 7 infants were born at 36 weeks all remaining infants were fullterm additional question asked overall how satisfied are you with the support you get from your partner response options ranged from 1 to 5 a sum score was calculated second the partner support subscale of the prenatal expectations scale for mexican americans provided a six item measure of expectations for partner support after the birth women also completed the pesma at six weeks postpartum reworded to assess actual experiences of support developed specifically for lowacculturated mexican american women the pesma is a culturallyrelevant measure of womens prenatal expectations and postpartum experiences sample items include your spousepartner will be there for you when you need him and your spousepartner will help take care of the baby items were rated on a five point scale from 1 to 5 and a sum score was calculated higher scores represent higher expectations for postpartum support or higher experiences of support the das and pesma scales were highly correlated and a composite score for partner support was calculated by summing the zscores for each scale prenatal economic stressmothers were administered the economic hardship scale the 20item ehs was developed for lowincome families as a subjective measure of the psychological sense of hardship it is advantageous over objective measures such as family income due to difficulties accurately quantifying income in populations with unpredictable income as well as problems interpreting the adequacy of a given income level based on unique life circumstances instead the ehs assesses the stress experienced when available resources are not adequate for appraised needs evidence for measurement equivalence and validity with mexican american english and spanishspeaking adults is detailed in barrera et al four subscales include financial strain inability to make ends meet not enough money and economic adjustments subscale scores were converted to zscores and summed higher scores indicate more economic stress depressive symptomsthe 21item edinburgh postnatal depression scale was given prenatally and at six weeks postpartum the epds has been validated in english and spanish higher scores reflect higher depressive symptomatology motherinfant interaction taska series of five structured videorecorded motherinfant observational episodes selected to elicit mild frustration for the mother and the infant were conducted the infant was in an infant seat with the mother seated directly across from himher the episodes included 1 free play 2 arm restraint 3 soothing 4 teaching task that reflects a skill 12 months beyond the infants capabilities and 5 peekaboo the total duration of the tasks was 2530 minutes cortisol samplingsaliva samples were obtained from infants and mothers at the 6week postpartum home visit samples were collected immediately prior to the first task and at 0 20 and 40 minutes after all the tasks were complete using salivette and sorbette sampling devices oral stimulants were not used and mothers were asked not to feed the baby for 30 minutes prior to collection saliva samples were frozen and mailed to salimetrics inc where they were assayed for free cortisol missing infant cortisol data were due to the following significant interference in assays insufficient saliva infant illness and problems in the home that prevented the interaction task cortisol values were logtransformed to correct for deviations from normality maternal postpartum cortisol values were used to calculate area under the curve with respect to ground as a measure of total cortisol across the task and area under the curve with respect to increase as a measure of cortisol reactivity to the task selection of control variableswe considered three types of control variables for evaluation confounds covariates and intermediate variables cortisol reactivity can be influenced by a wide range of factors not expected to be related to the independent variables including time of day infant waking or last infant feeding breastfeeding status temperature in the home and mothers use of medications caffeine or tobacco these variables were evaluated as potential covariates covariates do not explain relations between the ivs and the dependent variable because they are not in a causal pathway between the ivs and the dv it is not necessary to control for covariates but doing so may increase efficiency in estimation we selected covariates by empirical evaluation of their relation to infant cortisol although covariates are not expected to change the relation between the ivs and the dv we elected to take a conservative approach by analyzing models both with and without covariates confounding variables are factors that are associated with both the iv and the dv introducing bias into estimation of hypothesized causal relations potential confounds were selected by theoretical identification of variables that may be associated with prenatal support economic stress and infant cortisol potentially changing or explaining the relations between them potential confounds included household income maternal age education number of children or country of birth weeks pregnant at prenatal visit maternal postpartum cortisol levels and reactivity and prenatal depression for example lower household income or lower education may be associated with both higher prenatal economic stress and dysregulated infant cortisol dysregulated maternal cortisol may be associated with a stressful environment and may be a marker of genetic risk to infants because prenatal exposures that persist into the postpartum environment complicate efforts to isolate the impact of prenatal factors we also evaluated maternal depression and partner support at six weeks postpartum2 potential confounds were evaluated empirically those related to both the iv and dv were included in final models finally variables on an intermediate pathway between the iv and dv that may explain the effects of the iv on the dv were considered these included birth outcomes obtained from medical records at the hospital of birth for example a high stress prenatal environment may increase the risk of low birth weight which may explain six week infant cortisol responses data analyses preliminary analyseszeroorder correlations between study variables are shown in table 2 analyses of outliers identified eight infants with high cortisol values who were removed from analyses 3 we first considered potential covariates time of day of sampling was nearsignificant in predicting the linear slope of cortisol p 063 infants who were breastfed had a higher intercept p 001 and increasing linear slope p 027 a longer time since the last feeding predicted higher cortisol intercept p 002 no other potential covariates were significant predictors of any measure of cortisol activity therefore time of day breastfeeding status and time of last feeding were selected as covariates next we evaluated potential confounds older maternal age lower household income and a greater number of biological children were associated with higher economic stress but these variables were not associated with partner support the interaction of partner support and economic stress or any measure of infant cortisol mothers country of birth and number of weeks pregnant at the prenatal visit were not associated with economic stress partner support the interaction term or any measure of infant cortisol maternal education was negatively correlated with economic stress was predictive of infant cortisol intercept and was near significant for the linear slope and quadratic response such that infants whose mothers had less education had a lower baseline cortisol and greater reactivity than those with higher educated mothers higher prenatal depressive symptoms were correlated with higher economic stress and lower partner support but did not significantly predict any measure of cortisol activity potential confounds in the postpartum environment were also considered maternal postpartum auci and aucg were not correlated with economic stress partner support or the interaction term maternal aucg and auci were also not associated with infant cortisol reactivity or total cortisol postpartum maternal depressive symptoms were correlated with prenatal support and economic stress and predicted infant cortisol intercept and linear slope postpartum support was positively correlated with prenatal support and predicted infant cortisol intercept linear slope and quadratic response therefore we controlled for maternal education postpartum depressive symptoms and partner support in final models primary analyseswe used multilevel linear modeling to evaluate the influence of prenatal stress and partner support on infant cortisol response to the interaction tasks mlm is valuable for these data because it handles repeated cortisol measures nested within infant and because it allows for the simultaneous modeling of possible differences in change in cortisol over time across persons and does not limit data analysis to only complete cases the data were modeled using spss mixed with the repeated cortisol measures forming the withinperson dimension a variable time was created to reflect withinperson cortisol sampling order coded so that 0 baselineintercept 1 immediately after motherinfant tasks 2 20 minutes post tasks and 3 40 minutes post tasks the relation of this level 1 variable with the dv was included as a random linear and random quadratic effect partner support economic stress and the interaction of partner support and economic stress served as level 2 ivs continuous variables were centered at the sample mean pseudo r 2 was calculated as a measure of effect size for the quadratic term using the covariance parameter estimates for the model without the interaction terms relative to models with the interaction terms the pseudo r 2 represents the change in variance explained by the addition of the interaction of prenatal stress and support to the model models were first estimated with only the ivs next models were estimated with covariates maternal education postpartum maternal depressive symptoms and postpartum support were then included as control variables finally we evaluated birth outcomes as potential intermediate variables results infant cortisol response to the interactions multilevel models were estimated predicting the repeated measures of infant cortisol from prenatal partner support economic stress and the interaction of partner support and economic stress results are shown in table 3 there was a significant quadratic pattern in the cortisol response f 270 p 001 β 053 95 ci 0073 0033 indicating significant infant cortisol reactivity to the tasks across the sample the interaction term was significantly associated with the linear slope p 003 and the quadratic pattern of response p 003 pseudo r 2 17 there was also a significant effect of partner support for the linear slope p 001 and quadratic pattern of response p 001 indicating higher reactivity among infants whose mothers reported less prenatal support exploratory analyses were conducted to further understand the nature of the interaction by dividing the sample into high and low economic stress groups using a median split within the low stress group prenatal partner support had no effects on infant cortisol intercept slope or quadratic pattern of response however within the high stress group partner support was highly significant in predicting cortisol intercept linear slope and quadratic response additional exploratory analyses addressed the graphical pattern of results which suggested that infants whose mothers reported high stress and high support may have had elevated baseline cortisol and attenuated reactivity however prenatal support economic stress and their interaction did not predict baseline cortisol when the sample was divided into high and low support groups using a median split economic stress only predicted reactivity for infants in the low support group controlling for covariates the second model controlled for covariates including time of day time of last feeding and breastfeeding status the quadratic pattern of response remained significant for partner support p 002 and the interaction of partner support × economic stress p 005 controlling for potential confounds finally analyses were repeated controlling for potential confounds the quadratic pattern of results remained significant after controlling for maternal education postpartum depressive symptoms and postpartum partner support postpartum partner support did not predict any measure of cortisol response postpartum depressive symptoms also did not predict any measure of cortisol response maternal education remained a significant predictor of the intercept and was near significant for the linear slope and quadratic response evaluation of birth outcomes as intermediate variables the interaction of prenatal economic stress and partner support did not predict any of the birth outcomes contrary to predictions higher economic stress predicted a higher apgar score and higher prenatal support predicted lower birth weight finally we entered birth outcomes as predictors in a model with economic stress partner support and the interaction of economic stress and partner support covarying for time of day breastfeeding status and time of last feeding none of the birth outcomes were significantly related to any measure of infant cortisol and did not significantly affect any of the relations of economic stress and partner support to infant cortisol discussion the present study examined the interactive influence of prenatal stress and partner support on infant salivary cortisol reactivity in very lowincome mexican american families previous literature conducted predominantly with caucasian samples has focused primarily on main effects of prenatal stress on infant neuroendocrine and developmental outcomes we hypothesized that partner support during pregnancy would buffer against the negative impact of economic stress on infants cortisol reactivity at six weeks of age our results suggest that support from a romantic partner during pregnancy may play an important protective role in the development of infants stress reactivity systems for pregnant mexican american women experiencing considerable stress specifically we found that infants evidenced higher cortisol reactivity when mothers reported high economic stress during pregnancy coupled with low partner support relative to women reporting higher partner support or lower economic stress consistent with our results strong emphases on family ties and higher social support are theorized to be mechanisms through which the latina paradox is activated because our sample only included mexican american women we cannot generalize our results to majority groups or other ethnic minority groups given the unique cultural characteristics of our sample the powerful buffering effects of partner support may be unique among the latina community future research that attempts to replicate these results with other ethnic groups can provide valuable insight into the extent to which these processes are consistent across other cultures studies suggest that infant health benefits associated with the latina paradox may dissipate for more acculturated latinas given the number of first generation immigrants and low acculturative status of our sample it will also be important to evaluate whether the results hold in later generation or more acculturated families prenatal partner support appeared not merely to act as buffer against the negative influence of prenatal stress on infants cortisol reactivity but also to exert a unique protective effect over and above the impact of prenatal stress this effect held even after controlling for postpartum partner support suggesting that observed differences in cortisol reactivity may be traced to the unique influences of partner support during pregnancy although most studies investigating the role of partner support on infant outcomes have focused on postpartum support some have found similar evidence that prenatal partner support may exert unique influences for example feldman and colleagues found that support during pregnancy predicted as much as 31 of the variance in fetal growth our study is unique in evaluating the impact of prenatal support while controlling for support received in the postpartum period unlike previous studies we did not find main effects of prenatal stress on infant cortisol reactivity rather our results support a risk and protective model in which higher economic stress during pregnancy was associated with heightened infant cortisol reactivity only when combined with low partner support the low incomes of all participants in the sample may have limited the power to detect main effects of stress if it can be assumed that all participants were experiencing elevated stress relative to higher ses populations alternatively economic stress may not exert the same impact on infant cortisol activity as other forms of prenatal stress however our results suggest that in the face of considerable economic stressors supportive resources in the prenatal period are an important buffer of the impact on infant cortisol these results may be useful for the development of interventions aimed at the promotion of partner support during pregnancy for women with few economic resources the graphical pattern of results shown in figure 1 was such that infants whose mothers reported high economic stress coupled with high partner support appeared to show attenuated cortisol reactivity this pattern of results was not statistically significant exploratory analyses did not support significant differences in baseline cortisol or reactivity among infants whose mothers reported high support coupled with either high or low stress however similar to theories of stress inoculation it is interesting to speculate about the potential for strong support in the face of high stress to promote adaptive maternal selfregulation which may influence infant cortisol reactivity via biological or behavioral coregulatory mechanisms alternatively attenuated reactivity may be an early marker of hpa axis dysregulation associated with early life stress assessment of cortisol reactivity health and development at later ages will help determine whether attenuated reactivity is present and if so whether it is adaptive or maladaptive an additional aim of our study was to evaluate whether prenatal influences on infant cortisol reactivity operated through effects on birth outcomes however partner support prenatal stress and their interaction did not predict any of the birth outcomes and none of the birth outcomes were associated with cortisol reactivity our results contrast with previous findings that prenatal social support predicts better birth outcomes and prenatal stress predicts worse birth outcomes differences in sample characteristics may help explain this discrepancy our sample is unique because it only included lowacculturated hispanic families a population shown to have healthier birth outcomes than would be expected given elevated socioeconomic risk our finding that birth outcomes did not mediate the relation of prenatal stress and support to infant cortisol reactivity may not generalize to other ethnic groups more acculturated mexican americans or higher ses populations it is also possible that more highly stressed women for whom effects on birth outcomes may have been stronger declined to participate in the study finally our sample size may not have provided enough power to detect small effect sizes in the relation of prenatal stress to birth outcomes the observed effects of prenatal stress and partner support on infant cortisol reactivity may have acted through a third variable not considered here for example parenting and the parentinfant bond are potential intermediary pathways harsh or neglectful parenting styles have been associated with insecure infant attachment and insecure attachment has been linked to elevated cortisol reactivity women who experience high stress and low support during the prenatal period may be less effective at coregulating their infants reactivity during the mildly stressful interaction task aspects of the postnatal environment such as maternal depression may also induce epigenetic variation leading to altered biological responses although we found no evidence that postpartum depression or support explained the effects of prenatal experiences on infant cortisol reactivity it will be important for future studies to closely examine additional mechanistic pathways there are several limitations to the analyses first the study only included lowincome participants who selfidentified as mexican or mexican american the majority of whom were foreignborn spanishspeaking and low in acculturation although this sampling strategy provides a critical contribution to understanding the health of a high risk and understudied population our results cannot be generalized to other racialethnic groups or more acculturated mexican americans similarly our analyses only included women who reported a current romantic partner at the prenatal interview results should not be generalized to women without romantic partners second this was not an experimental study despite the prospective design there may be other unmeasured confounders that could explain results third infant hpa axis reactivity reflects the influence of genetic variation and geneenvironment interactions infants of mothers who experience considerable prenatal stress andor low support may have inherited genetic vulnerabilities that influence biological sensitivity to the postpartum environment although we do not have genetic measures we address this concern by controlling for motherrated measures of prenatal and postpartum depressive symptoms and postpartum partner support which would presumably be similarly affected by personality or genetic factors we also evaluated maternal postpartum cortisol a potential marker of genetic influence it did not predict infant reactivity or explain the relation of prenatal factors to infant cortisol however even if an unmeasured genetic factor is the underlying mechanism our results suggest that prenatal stress and partner support are easily measured markers of prenatal influences on infant neurobiological outcomes further stress and support are potentially modifiable targets for intervention in the prenatal period for example urizar and muñoz reported that infants born to lowincome spanishspeaking women who received a prenatal stress management intervention had lower salivary cortisol levels than those in the control group finally because we did not measure maternal hpa activity during pregnancy we cannot evaluate in utero hormone exposure as a mechanism this study has a number of strengths that contribute to a growing literature on prenatal programming effects on infant neurobiological development latinos are the largest ethnic minority group in the us increasing by nearly 45 since 2000 latinos of mexican origin represent the largest proportion of this growth the risks for infant health associated with prenatal stress are particularly salient for lowincome hispanic women who compared to nonhispanic white women are more likely to live in poverty less likely to have graduated from high school and less likely to have health insurance however strong cultural values of family and social support may provide important protection for mexican american infants longitudinal studies such as this beginning in the prenatal period and controlling for potential confounds offer an ideal opportunity for a comprehensive understanding of the shortand longterm risk and protective factors contributing to the health of mexican american children our study expands literature on the effect of prenatal stress by evaluating partner support as a buffer of the negative consequences for cortisol reactivity in infants born to lowincome mexican american women the results suggest that partner support may dampen the impact of prenatal stress on infant cortisol regulation potentially promoting more adaptive infant health and development prenatal stress and partner support interact to predict infant cortisol reactivity1 1 for display purposes low support and stress were set at 1 sd below the sample means high support and stress were set at 1 sd above the sample means t0 pretask t1 immediately posttasks t2 20 mins posttasks t3 40 mins posttasks predicted logtransformed cortisol values were subjected to antilogtransformation in order to display cortisol values in an interpretable metric zeroorder correlations

maternal exposure to significant prenatal stress can negatively affect infant neurobiological development and increase the risk for developmental and health disturbances these effects may be pronounced in low ses and ethnic minority families we explored prenatal partner support as a buffer of the impact of prenatal stress on cortisol reactivity of infants born to lowincome mexican american women women n220 age 1842 84 spanishspeaking 89 foreign born modal family income 10000 15000 reported on economic stress and satisfaction with spousal partner support during the prenatal period 2638 weeks gestation and infant salivary cortisol reactivity to mildly challenging motherinfant interaction tasks was assessed at womens homes at six weeks postpartum multilevel models estimated the interactive effect of prenatal stress and partner support on cortisol reactivity controlling for covariates and potential confounds infants born to mothers who reported high prenatal stress and low partner support exhibited higher cortisol reactivity relative to those whose mothers reported high support or low stress the effects did not appear to operate through birth outcomes for lowincome mexican american women partner support may buffer the impact of prenatal stress on infant cortisol reactivity potentially promoting more adaptive infant health and development

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introduction internationally many populations are aging and governments are seeking to encourage the extension of working lives in order to counteract potential associated labor market shortages yet employers do not necessarily see the extension of working lives as a solution to potential labor shortages and older workers face a range of barriers to their labor market participation running head older workers and shifting intergenerational dynamics 3 this paper draws upon exploratory and inductive indepth qualitative research undertaken in hong kong hong kongs population is aging more rapidly when compared to many countries in asia europe and north america there are concerns that this will exacerbate existing labor shortages however older workers face persistent barriers to their labor market participation the exploratory research presented in this paper sought to understand why employers do not see older workers as a solution to labour market shortages in hong kong ie in labour process terms why are they not making the most of this potential labour the research findings suggest that employer policy and practice are in part shaped by the social responsibility that employers feel towards different generations of workers this is an issue that has not been explicitly articulated or explored in previous researchalthough there has been explicit consideration of how later life employment is shaped by household and family contexts as such it is argued that the research presented in this paper supports calls to consider aging as a process whichis actively negotiated through experienced in and constituted alongside sociocultural settings when examining employer policy and practice towards older workers the aging workforce in hong kong hong kongs population is aging rapidly concerns have been expressed both by government and business that the aging of the population alongside the low birth rate will exacerbate existing labor shortages compromising economic growth some have argued that older adults who are able and willing to keep working could counter the shrinking labor force and could be key players in a knowledgebased economy that emphasizes life experience however workers in hong kong retire much earlier than in many other countries even though there is no statutory retirement age there is a generally accepted retirement age that ranges from 55 to 60 years thus government is increasingly looking at unleashing the potential of older workers and has raised the retirement age to 65 years for civil servants and 60 years for those working in disciplined services perhaps with the expectation that private sector employers will follow suit employers do not necessarily see the extension of working lives as a solution to potential labor shortages despite efforts to extend working lives in hong kong older workers continue to be subjected to workplace age discrimination and negative stereotypes about their abilities government efforts to encourage the extension of working lives have been criticized for not intervening in human resource processes and not been prescriptive in tackling age discrimination they have tended to be limited to encouraging voluntary good practice few companies have developed formalized strategies to take into account the aging of the population and every effort to introduce age discrimination legislation or change retirement arrangements has been opposed by businesses this opposition is underpinned by the belief that current human resources practices are adequate and effective and that more flexible work arrangements would be administratively cumbersome or would hinder the economic efficiency of hong kongs flexible labor market running head older workers and shifting intergenerational dynamics generations and the workplace in hong kong as previously detailed in this paper research in hong kong highlights that older workers face a range of employer policy and practice related barriers to their labor market participationmirroring international trends while this research has drawn attention to workplace age discrimination and negative stereotypes about the abilities of older workers it has not explicitly articulated or explored broader aging dynamics the exploratory research presented in this paper highlights the need to locate employer policy and practice towards older workers within the cultural social and organizational context of intergenerational social relationships which constrain older workers choices the findings presented in this paper draw attention to two issues generational stereotypes in relation to organizational and societal intergenerational dynamics and employers responsibilities towards different generations in the wider academic literature there is a fascination with generations and the impact that these socially constructed groupings may have on a variety of organizational outcomes there is an extensive human resources literature that argues for the need to understand the wants and optimize the talents of different generations this literature however often employs generational stereotypes which may create false assumptions about expected behaviour and are often not supported by valid and robust empirical evidence however as research on the experiences of older workers reveals these generational stereotypes continue to be key barriers to the extension of working lives running head older workers and shifting intergenerational dynamics this paper reveals how intergenerational relations embed employer policy and practice and details some of the social responsibilities employers feel towards different generations in hong kong social development has emphasized youthfulness thus older workers are seen as blocking opportunities and should make way for their younger colleagues this idea of jobblocking is also apparent internationally traditionally retirement and dependence on adult children has been considered a normal part of aging and an indication of social status in hong kong this is bound up with the traditional confucian doctrine of filial piety which encompasses attributes such as showing respect being obedient taking material as well as emotional care of aged parents therefore in this context if government seeks to extend working lives they may be seen as immoral while one might expect that older people are valued members of society because of this doctrine they are also framed as having lost the ability and right of social participation and are categorized as a burden to the family and society hence research finds perceptions that younger workers should have priority in terms of training opportunities and employment therefore employers may be less willing to invest in older workers this focus on the training and development of younger workers is an international trend however with regards to filial piety research shows that expectations for filial piety are not apparent in ukborn older people while older workers are expected to make way for their younger colleagues filial expectations of and the support provided by the younger generation in hong kong are declining the reasons for this include cultural attitudes reduced intergenerational contact and coresidence in urban areas prolonged life expectancy and the changing patterns of work family relationships may now be more grounded in reciprocity and pragmatic utilitarianism rather than responsibility and obligation thus in this context middleaged adults in hong kong may not expect that they can depend on their family networks for support during retirement bai shows that older people in hong kong do not have a stable retirement income and are reluctant to ask for or are not expecting to receive financial support from their adult children in this context financial care expectations are increasingly focused on formal sources rather than informal sources yet it has been identified that formal sources of financial support in retirement in hong kong may not be developed enough to meet this demand it has been argued that the insecurity that older people may experience is arguably exacerbated by the very limited public and third sector formal support available in hong kong many workers might not be making private savings for retirement the financial security provided by the public pension system is also limited the mandatory provident fund a compulsory pension fund was only introduced in december 2000 and even once the scheme is mature the extent to which it will be able to support older people has been questioned it is therefore interesting to consider whether changing filial expectations and the resultant intergenerational relations are shifting the position and status of older workers given the decline of filial piety is the labor market participation of older workers more generally accepted by employers or is still the expectation amongst employers that older people should withdraw from the labor market and that young people should be enabled to progress what are the responsibilities that employers feels towards different generations running head older workers and shifting intergenerational dynamics methods the aim of this exploratory research was to understand the impact of the aging workforce in hong kong and why older workers are not being seen by employers as a solution to labor market shortages the research focused upon the service sector which has been growing rapidly in hong kong and in 2015 contributed 45plus 50plus and 5564 years other research identifies that workers may face age discrimination in hong kong from the age of 43 in order to strike a balance for the purpose of this research the research team broadly defined older workers as those aged 50plus but participants were also asked to define an older worker from their perspective key informants interviews thirteen key informant semistructured interviews were conducted both onetoone and joint interviews were undertaken a purposive sampling approach was used the 15 individual key informants included representatives from employer groups and associations older peoples organizations and social enterprises supporting running head older workers and shifting intergenerational dynamics older people representatives of organizations set up by the governmentgovernment bodies and academics and representatives from other organizations with expertise in the subject area key informants were identified using contacts and networks already known to the authors and their colleagues internet searches and analysis of the academic literature were also used to identify key informants the interview schedule was designed so that it was exploratory as one purpose of these interviews was to help refine research priority areas as well as adding to the research teams knowledge of the hong kong context issues identified in the academic literature and the demographic data also shaped the interview schedule design the interviews gauged key informants views on the impact of population aging on employers in the service sector the policy and practice employers have in place the opportunities and challenges for later life working in hong kong and directions for future policy and practice the majority of participants were hong kong based the interviews were conducted in english and were primarily conducted facetoface in hong kong with a small number via skype during january 2017 employers interviews twenty semistructured interviews were conducted with service sector employers both onetoone and joint interviews were undertaken the interviews were conducted facetoface in english in hong kong during march 2017 a purposive sampling approach was used employers were identified using contacts and networks already known to the authors and their colleagues internet searches and mining of online employer databases were also used to identify employers the participating employers encompassed a range of industries within the service sector and included smes and larger companies and businesses operating internationally and in hong kong only the running head older workers and shifting intergenerational dynamics participants all with human resources experience included managing directors heads of hr departments and company foundersproprietors the interview schedule included issues highlighted in the key informant interviews and identified in the academic literature and demographic data as relevant to the study the interviews explored participants opinions with regards to future company trends and the impact of demographic change as well as their attitudes and policypractice towards older workers some participants requested that they were interviewed as a professional with service sector hr experience rather than representing a particular company for reason of confidentiality or retirement in these instances the interview schedule was generic and did not include specific questions about the company that the participant was or had been working for table 1 provides an overview of the employer participants where a generic interview schedule was used details regarding organizational size cannot be provided table 1 about here data analysis all interviews were audio recorded with the participants permission the interviews were transcribed and systematic but iterative thematic analysis was applied to identify key themes in the data with the assistance of the computer software nvivo11 as an exploratory piece of research the analysis followed an inductive approach it should be noted that key informant interviews and the employer interviews were analyzed separately as the purpose of the key informant interviews was to help refine research priority areas for the employer interviews however the data from both groups of participants is presented together in the following sections as a further step of the data analysis involved reviewing key themes across both sets of data to identify common issues and similarities and differences in views in order to reduce researcher bias and to increase the internal validity or credibility of the analysis author were involved in the coding of the transcripts while author led the coding for a number of transcripts running head older workers and shifting intergenerational dynamics their analysis was checked by author and recoding was undertaken as necessary construct validity was achieved by seeking feedback and direction from the research advisory groupcomposed by six academics and four members of other relevant organizationswho were invited to offer guidance and support throughout the research stages findings the key informant and employer interviews sought to understand more fully the impact of the aging workforce in hong kongs service sector and whether employers consider older workers as a solution to labor market shortages the key informants outlined how government awareness and discussion of population aging had increased across policy areas however the majority of the key informants felt that while employers were aware of population aging they had not necessarily taken any action yet to counter any negative effects on their workforce or to support their older workers these assertions are supported by the accounts given by employers in terms of their policy and practice towards older workers this was despite some employers viewing the extension of working lives as a solution to population aging the analysis of the key informant and employer transcripts highlighted that employer policy and practice towards older workers could in part be explained by feelings of social responsibility towards younger people in the context of demographic change and shifting intergenerational dynamics the presentation of the findings is structured into sections developed from three overarching themes emerging from the analysis generational stereotypes employers social responsibilities towards younger and older generations and how intergenerational relations and generational stereotypes and employers responsibilities shape policy and practice towards older workers and thus opportunities to extend working lives the three sections are subdivided into subthemes running head older workers and shifting intergenerational dynamics generational stereotypes the first overarching theme presented from both the key informant and employer interviews relates to the stereotypes associated with different age groups while older workers are easier to manage they are not felt to have the right skills defining the older worker in both the key informant and employer interviews the characteristics that defined older workers were discussed revealing a number of pervasive stereotypes that mirror some of those used in the hr literature about the capabilities of workers based on their age the stereotypes in terms of defining characteristics often compared older and younger workers in terms of their skills and deficits in terms of positive stereotypes older workers were said to be loyal hardworking knowledgeable experienced patient and kind in terms of negative stereotypes older workers were characterized as not very good with it dislike taking orders from younger colleagues less able less flexible slow likely to take sick leave and have poor health put into the context of the features of the modern workplace as defined by the participants older workers were perceived as not having the skills required and younger workers were felt to be better suited as such aging is understood in terms of deficit with regards to the skills needed by employers for example one employer stated their reasons for employing those in their 20s and 30s to be very frank we need to employ people with young age because they are maybe more adapt to the new business environment and secondly they are more intelligent with the computer and also the thinking is more openminded key informants also mentioned that employees mindset and selfesteem could be a barrier to the extension of working lives as they could think less of their own abilities compared to other employees and have selfdefeating perceptions running head older workers and shifting intergenerational dynamics in some industries perceived client demand also drove the focus on younger workers the emphasis by employers in the hospitality and retail sectors on the appearance and aesthetics of their employees at the detriment of older workers has been noted elsewhere however in other industries employers saw being older as an advantage as age was equated with experience managing and retaining younger workers comparisons between older and younger workers were made with it becoming apparent that the skills attributed to younger workers were valued these were skills that older workers were felt to lack however although attention was focused on recruiting and providing opportunities to younger workers a common theme across the employer interviews in particular was the difficulties faced in understanding and managing young people links can be made here to the extensive youth studies literature that highlight the more general social concerns about young people in hong kong and their political values in terms of the workplace management styles and practices were not necessarily felt to have caught up with the values and expectations of the younger generation the younger generation now is not looking so much for a fixed job in a very defined hierarchy where they can see themselves moving up so i think its fair to say they are looking for quite flat structure whilst being quite fluid hence managers did not always understand their younger workers whereas money previously was a key motivator for older workers younger generations did not put as much value on salary as their older colleagues one key informant felt that this could be explained by political uncertainty and a realization by young people that given the economic context they were never going to be as financially secure as their parents at the same time some employers also felt that younger workers additionally wanted to rapidly progress have high salaries and be challenged in their work satisfying these expectations was a concern for many employersespecially in the context of some industries where building experience gradually over time was central to progression or where there were an oversupply of graduatesyounger workers employers felt that younger workers were unable to provide longterm stability to a workplace and retention was a challenge for many employers as young people often changed jobs frequently in an effort to progress rapidly in many cases younger employees job expectations were not being met the finance industry may not have enough jobs that will require university graduates… 30 years ago…we recruited a high school graduate for a clerk position now we recruited university graduate for a clerk position so how can we satisfy the young people in the job in summary while employers valued younger workers in terms of their perceived skills they struggled to manage and retain these employees this presented challenges in terms of organizational stability and sustainability older workers were easier to manage but were not felt to have the right skills and attributes social responsibilities towards different generations the second overarching theme relates to the social responsibilities employers feel towards younger and older generations employers do not necessarily feel that they have a responsibility towards older workers although at the same time they recognize that filial piety is declining the labour market positions of older and young workers employers felt that they had a broader social responsibility to allow young people to progress in the labor market key informants outlined that while older people were respected in society generally there was at the same time an expectation that older workers should withdraw from the labor market so that they were not impeding the promotion of younger running head older workers and shifting intergenerational dynamics workers these views were reiterated by the employers who outlined that while being aware of population aging and labor market shortages they did not want to stall younger workers how do you accommodate older workforce how do you do that without stalling the younger peoples career path this desire to provide opportunities for younger workers can also be linked to the characteristics associated with different age groups with young people being seen as fresh i guess if our retirement age was 65 or 67 and people could stay longer then fewer jobs would be available for younger people to take and i think that our company is probably conscious of the need to support to try to encourage young people to join our firm because we need new young fresh people young blood in this context there was an expectation that older people should scale back and withdraw from the labor market recruiters did not present companies with older candidates and managers were not encouraged to hire older workers employers also felt that older workers demanded higher salaries because of their age with a focus on recruiting and promoting the progression of younger staff some employers had fixed retirement ages used early retirement packages or laidoff older workers examples were also given where employers may increase the workload of older workers to such an extent that they choose to leave their job because they cannot cope with the pressure filial piety it was clear from many of the interviews that employers do not necessarily feel that they have a social or moral responsibility towards their older workers with however a few exceptions it is therefore interesting to consider whether this attitude could be explained by an expectation that older people would be supported by their families this lack of feelings of responsibility by employers is especially problematic for those older workers who might have no choice but to remain in work because of financial necessity running head older workers and shifting intergenerational dynamics these workers were often in lowskilled and lowpay occupations and did not have adequate private savings participants were aware that those in lowskilled and lowpay occupations might have no choice financially but to carry on working many of the key informants did not feel that the mandatory provident fund was sufficient to support people in retirement when discussing the situation of these older workers mention was not necessarily made of these workers being supported by their families instead their financial situation was framed in terms of a lack of formal retirement safety net or savings for the lower income group because of the lack of labour protection and very low retirement benefit and low saving as a result they want to extend their working life as previous research has shown as a result of a range of factors filial piety is declining so many older people cannot rely on their adultchildren to support them in retirement when reflecting on their own situation some participants themselves highlighted that they did not expect to be supported by their children although interestingly these participants did want to support their own parents if my role is daughter or son i dont want my parents to work like 60 or 65 yeah i want them to enjoy their life but i respect their decisions an important consideration mentioned by participants was that when considering the extension of working lives for the current generation of older workers it needed to be acknowledged that older workers may need to carry on working as they are financially supporting their parent and also their children who are still in school or college first they have to support their parents for this much longer second they get married a little bit late…by their 50s…their children are still in college age so they have to support them running head older workers and shifting intergenerational dynamics however going forward it is unclear whether future generations of older workers will have these same filial responsibilities although the employer quoted below argued that one reason for encouraging the integration of young people into the labour market was that they could support an ageing population there is less young people to work in this society who are going to raise the old people so you will need a lot of more young people to work in the society to pay tax to raise the older people extending working lives the third theme considers how intergenerational relations and generational stereotypes and employers responsibilities shape policy and practice towards older workers and thus opportunities to extend working lives opportunities for extending working lives as can be gleaned from the findings presented above older workers do not occupy a valued position within the labor market they are expected to make way for younger workers and are not seen to bring valuable skills to the workplace however there were some opportunities for older workers to extend their working lives for example horizontal andor sideways job opportunities might be provided older workers could continue on shortterm contracts or as freelance consultants often mentoring younger colleagues those in senior highskilled positions continued to work well beyond the normative retirement ages as seniority in the workplace is still respected we do have a number of them that have already reach 60 but they are still with us but with different kind of the nature of the employment they work for us as the kind of the consultant yet contract and freelance work is precarious as older workers do not have the guarantee of continued employment and not all older workers are provided with the opportunity to extend running head older workers and shifting intergenerational dynamics their working lives those in contract and freelance work could face annual reviews thus their continued employment was not guaranteed as such it can be argued that labour market precarity affects younger and older workers alike indeed older workers could be a driving force for the growth of the precariat for the certain position that we want we will extend the employment for them and thats reviewed casebycase or yearbyyear older workers on these contracts might also be barred from management roles in order that the younger generation can take these positions it is also questionable as to whether these opportunities were available to those in lowpaid and lowskilled work selfreflection by some of the participants in particular highlighted the inequalities in terms of opportunities depending on a workers position within an organization those who were company ownersemployers had choice in terms of their retirement timing employees lacked this choice it so happened that i am the employer so i can choose my retirement age but then i also thinking lets say i am an employee working for somebody else what will happen to me when i have to retire when i am 60 future labour market opportunities for older workers there was a suggestion by some of the interviewees that older workers might in the future occupy more certain position in the labor market as a result of the difficulties that employers have in retaining their younger colleagues for one employer this behavior by younger workers could be attributed to them knowing that at age 50 they may be forced out of the labor market together with the lack of family and social support in their old age this meant that individuals felt the need to earn as much as possible when they were young and to progress as quickly as possible this could mean that younger people changed jobs regularly trying to get a higher salary running head older workers and shifting intergenerational dynamics employees want to get most money when they are young they know after age 50 its very difficult to get money…people have to protect themselves and they have to change job once every three or four years in order to get more money save up more money for the retirement etcetera this higher turnover of younger staff members was also attributed to poor employment protection in hong kong and to the fact that young people were looking to advance in their career but also to travel and experience different things before settling on a career in this context some employers felt that they had no choice but to retain older staff because of the high turnover of younger cohorts thus there is a suggestion that some employers see a need to maintain older workers as they offer stability experience and soft skills built up over time that younger workers do not however it is hard to generalize whether this suggests a change in attitude towards older workers because of the small selfselecting sample the interviews also suggest that in multigenerational workplaces stereotypes about older workers are still pervasive and the onus is on older workers to modify their behaviors in order to integrate with younger workers it is not clear whether there are the same expectations of younger workers discussion hong kongs population is aging rapidly and there are concerns that this will exacerbate existing labor shortages compromising economic growth while government has sought to encourage the extension of working livesalbeit these efforts have been limited in their scope older workers face a range of employer related barriers to their extended or prolonged labor market participation employers have not necessarily taken any action despite a rapidly aging population running head older workers and shifting intergenerational dynamics 20 growing skills gaps and labor market shortages this exploratory research has shown that this lack of employer action needs to be understood within the broader intergenerational dynamics and the position of older and younger people within hong kongs society to date the research base regarding older workers and the extension of working lives has tended to locate age at the individual level rather than taking an embedded view of aging within broader social structures and age dynamics in this paper it has been highlighted that in order to understand employer policy and practice towards older workers and make progress in terms of addressing potential labor market shortages that might result from this demographic change an approach that pays attention to the social position of both younger and older workers in the organization and society is required as such policy solutions need to take into account the intergenerational dynamics in hong kong in hong kong social development has emphasized youthfulness and the need to prevent older workers from blocking the opportunities of the younger generations while it could be argued that this trend could be unique to the hong kong andor asian labor market context notions of jobblocking have been identified elsewhere employers participating in this research felt that they had a social obligation to allow young people to progress in the labor market and therefore they did not necessarily view the extension of working lives as a solution to labor market shortages filial expectations of and the support provided by the younger generation are declining it could be argued that filial expectations in hong kong increasingly mirror those in other countries added to this selfreflection from participants highlighted that going forward they did not expect support from their children although the participants themselves said they would support their parents in response to the question posed earlier in the paper with regards to whether the labor market participation of older running head older workers and shifting intergenerational dynamics 21 workers more generally accepted by employers given the decline of filial piety employer attitudes are not keeping up with these changing expectations and they do not necessarily feel that they have a social or moral responsibility towards their older workers thus it can be suggested that employers feel more responsibility towards younger generations than to older generations there were some opportunities for older workers to extend their working lives as consultants but often these workers might be barred from management roles although it must be noted that the abilities of older workers were recognized employers often fell back onto negative stereotypes which mirror those observed internationally there were positive stereotypes associated with older worker often discussed alongside perceived problems associated with younger workers thus it is apparent that while employers may feel a responsibility towards younger workers and they value the skills associated with them they do not necessarily find them unproblematic employees employers felt that younger workers did not provide them with workplace longterm stability whether this is the result of younger workers being aware that they may be forced to withdraw from the labor market as they get older requires further research in this context some employers felt that they had no choice but to retain older workers however it is hard to generalize whether this suggests that employers are increasingly valuing older workers more generally the research suggests that negative stereotypes are pervasive and the onus is on older workers to modify their behaviors in order to integrate with younger workers the authors of this paper would suggest that these findings indicate an approach that acknowledges that aging is a process that is experienced and constituted alongside sociocultural settings as demonstrated in this paper experiences of aging in the workplace are shaped by the ways in which organisations both react to and interact with…external running head older workers and shifting intergenerational dynamics 22 environmental factors this paper has revealed the broader landscape of what aging at work means as well as the differences between how aging is understood in the home versus the workplace as exemplified in this paper the doctrine of filial piety sees older people are valued members of society but within the workplace aging is understood in terms of deficit in terms of the skills needed by employers limitations there are research limitations in this study the sample size was small which raises questions about the external validity or transferability of the findings although it should be noted that the aim of qualitative research is seldom generalization as a result of the sample size the diversity of policies practices and attitudes may not be revealed and therefore further research with a larger sample may be required nevertheless this study reveals the importance of considering intergenerational relations when researching older workers and the extension of working lives the research does not examine the experiences of older workers themselves as it is beyond the scope of this study further research in this area would be pertinent it has been suggested that hong kong diverges from other national contexts in terms of the importance of intergenerational social relationships and further research would be also useful to ascertain whether employer policy and practice are embedded within the social responsibilities that employers feel towards different generations to the same extent in other national contexts respondents were not asked to disclose their age during the interviews therefore conclusions cannot be drawn as to whether this influenced their attitudesalthough there was some selfreflection from the respondents in terms of them being workers andor some did disclose their age incidentally during the course of the interview running head older workers and shifting intergenerational dynamics conclusion drawing on indepth qualitative research undertaken in hong kong this paper locates employer policy and practice within the social responsibilities that employers feel towards different generations and the value attached to different age groups in the context of demographic change and shifting intergenerational dynamics it has highlighted the need to locate employer policy and practice towards older workers within the cultural social and organizational context for example in terms of the contributions of these three contexts to older workers outcomes filial piety is declining and there is limited alternative socioeconomic support for older people stereotypes towards older workers are pervasive and youthfulness is emphasized in social development in terms of organizations perceived client demand on the one hand driving the focus on younger workers but on the other hand management styles and practices were not necessarily felt to have caught up with the values and expectations of the younger generation thus the experience of aging as an insecure process but could be ameliorated by specific policy responses for instance the promotion of the business case for an age diverse workforce could contribute to a change in employers and societys attitudes towards older workers antiage discrimination and the introduction of a minimum retirement age could reduce insecurity and inequality in the aging process initiatives to increase lifelong learning opportunities could extend working lives while at the same time limiting business opposition to previous mentioned measures all these policy initiatives could facilitate the extension of more secure and less precarious working lives and create more secure aging processes however a key message from this research is that those responsible for developing and implementing these policy solutions need to take a holistic view of the factors shaping employer policy and practice towards older workers and the aging process author biographies valerie egdell is associate professor in the business school edinburgh napier university valerie has a phd from newcastle university that examined how carers of people with dementia mobilize their support networks and draw social

many governments are seeking to encourage the extension of working lives to counteract potential labor market shortages that might result from population aging nevertheless research shows that older workers continue to face a range of barriers to their labor market participation however this research has not tended to take a holistic view of the factors shaping employer policy and practice or acknowledge that older workers experiences are embedded within broader social structures and age dynamics this paper reports on exploratory qualitative research undertaken in hong kong it demonstrates how employer policy and practice towards older workers are shaped by intergenerational dynamics and by the social responsibility that employers feel towards different generations it is argued that in order to more fully understand employer policy and practice towards older workers an approach that acknowledges the social context and position of different age groups is required

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introduction the purpose of this research is to examine the relationship of gender equity to faculty compensation career advancement and access to leadership roles in selected colleges of business in finland jamaica and the united states globally women still exist in a world where parity is often not reflected in the four key measures of …economic participation and opportunity educational attainment health and survival and political empowerment for example according to weinstein participation of women in the united states labor force nearly doubled from 34 of workingage women in the labor force in 1950 to almost 57 in 2016 similarly in europe the employment rate for women is 67 compared to 79 for men furthermore according to the 2021 world bank data report the total labor participation rate for women in jamaica is 6028 compared to 7105 for males thus globally there is a significant increase in women participating in the workforce however women still have a lower paid employment participation rate than their male counterparts in both developed and developing countries equal opportunity and employment policies are being legislated and enacted to protect the rights of women and other marginalized populations women 2015 furthermore these disparities in the treatment of women are evident in higher education specifically in traditionally maledominated disciplines such as science technology engineering math and business thus the issue of gender equity is of interest to the researchers because this imbalance spreads throughout developed and developing societies making this research very significant for too long women have been left behind regarding compensation professional advancement and leadership roles especially in science and business hence the authors address the following questions research questions 1 to what extent are female faculty members in business schools compensated differently than male counterparts 2 what factors explain differences in the career advancement of female faculty in business schools 3 to what extent are leadership positions in business schools determined by gender the authors answered each question in the context of the theoretical perspectives used to anchor this study theoretical perspectives the three relevant theoretical perspectives that anchor this research are feminist socialist theory socialization theory and human capital theory at the heart of these theories is gender equity as shown in figure 1 gender equity is and has been the heart of these theories however gender equity is not only theoretical but has practical and procedural implications for improving the quality of life for women worldwide figure 1 shows the intricate relationships among the three relevant theories guiding this research equity is at the center because it is a focal point of discovery and is directly and indirectly influenced by human capital assumptions social and cultural norms or mores gender equity impacts and is impacted by how females perceive themselves in their social and cultural norms furthermore gendered socialization and the economic engine that drives human capital decisions in society continue to perpetuate systemic inequities toward females feminist theory viewing inequity from a feminist socialist perspective suggests that established cultural norms and institutionalized and engrained economic and patriarchal systems influence how members of society are viewed and ultimately treated wharton postulates that how people are regarded and treated is based on how each individual sees themself and often how others view that individual based on established norms and institutionalized structures according to mundy bickmore hayhoe madden and madjidi feminist theory is based on peoples own perceptions of their place in society not only on what policymakers or bureaucrats may see as their path to progress thus feminist theory suggests that how a female sees herself may be based on socialization social strata economic power gender race or any other defining factor which is very likely how she will construct her reality resulting in how she is perceived and treated by others powell suggests that the deconstruction and reconstruction of how members of society regard gender roles are crucial to recasting how men and women are essentially viewed and treated by members of society ledford maitra mundy et al andnicholson advance that postmodernist feminist theorists have debunked gender essentialism espoused by many early feminist theorists it therefore suggests that women should not be viewed and ascribed expected behaviors based on specific roles they generally assume these roles include but are not limited to childrearing caregiving and other historically and culturally specific expectations feminist theorists assert that if more women are in leadership roles and are perceived in a positive light by both men and women then it is very likely that how other women and men view them will help in the deconstruction and reconstruction of how women are viewed and compensated in the society inequitable social and institutional structures form the nexus of inequities experienced by women and many marginalized groups the data from the 2011 american association of university professors report compiled by curtis advances the notion that even though more women are graduating from institutions of higher education with advanced degrees when compared to males there is still a disproportionate number of women who are employed as fulltime faculty versus adjunctparttime faculty feminist theorists purport that societal constructs including social stratification should no longer dictate the treatment of women in society social stratification theory according to bowles social stratification is defined as the systematically unequal distribution of power wealth and status within society social stratification theory suggests that how men and women are treated in society indicates the power dynamics wealth and status of men versus women within a particular society how males and females are treated by the same and opposite sex within a society is crucial in assessing the impact of gender inequity and inequality within cultures hence many females may opt to leave a discipline because they do not feel they are treated equitably for example many female faculties are the minority in traditionally maledominated disciplines of stem and business these faculties often feel out of place because they do not experience what maslow refers to as a sense of belongingness many eventually leave these traditionally maledominated disciplines because they often feel like a misfit coupled with the fact that they have few if any advocates hence many women leave the organization or workforce for other lowerpaying and more gender proportionate jobs leaving their jobs for less paying jobs perpetuates inequities many women endure the lower power positions ascribed to women in a maledominated historical cultural and social structure lead to women being seen and viewed as less valuable these challenging inequities are persistent but less glaring in developed countries where the gender gap is less when compared to many developing countries we found that social stratification through entrenched and inequitable institutional structures continues to influence gender equity negatively thus the challenge that many female faculty members continue to encounter is defeating the entrenched patriarchal embedded societal system that has and continues to govern most societies in these societies there is generally powerful rhetoric of valuing human capital however upon a more indepth examination of such rhetoric one will find that human capital as a vehicle of social and economic mobility is not the same for both men and women human capital theory as is used in this paper human capital theory refers to the epistemological framework that guides the understanding of the relationship between the expected positive impact of education and training on the explicit and implicit value an individual brings to the workforce hence the more education and training an individual receives they are perceived as more valuable to employers nafukho hairston and brooks suggest that human capital theory the main outcome from investment in people is the change that is manifested at the individual level in the form of improved performance and at the organizational level in the form of improved productivity and profitability or at the societal level in the form of returns that benefit the entire society this suggests that males are generally perceived as being more productive and profitable compared to many females the human capital perspective in various societies generally guides how gender is perceived and treated in relation to power human capital models continue to be biased towards men at the economic expense of women the languages and formulae used to craft benefit policies often favor males over females regarding resource access training familychildcare leave health and wellness options additionally mundy et al caution against the negative impact of popular views on human capital theory as those espoused by noted human capital theorist theodore schultz views espoused by those who conform to schultzs perspective on human capital continue to harm the treatment of women in the workplace mundy et al quote schultz as advancing the argument the distinctive part of human capital is that it is part of man it is human because it is embodied in man human capital theorists such as schultz do not account for women as essential to the economic wellbeing of a nation viewing women as an unimportant part of human capital arguably leads to the continued inequity in policies used by numerous institutions and organizations to manage their people the human capital disparity as it relates to proportionate and equitable distribution of women in maledominated disciplines in higher education is a direct reflection of the global trends that exist thus human capital and socialization theories are the primary drivers for developing the proceeding conceptual framework with feminist theory supporting both together all three theories provide a solid foundation on which this research is anchored and conceptualized gender equity conceptual framework incidences of gender inequities continue to exist in all facets of our society report 2017report 2020world economic forum global gender gap report 2018 for example in the european union a significant gender gap still exists for fulltime employment of men and women according to the european institute for gender equality report the gender gap in employment in the eu is wide and persistent with the fulltime equivalent employment rate of 40 for women and 56 for men among couples with children the fte employment rate is 28 percentage points in favour of men higher education institutions are not immune to gender inequitys marginalizing impact on female faculty especially regarding compensation leadership and upward mobility in this research the term framework is used because of its broad appeal and precise meaning hence the framework in this research refers to methods of research and planning for assessing and promoting gender issues in institutions specifically the two primary reasons for the framework were based on the literature reviewed and having a framework appropriate for the unit of research gender equity versus using other terminologies such as tools or methodology from the literature reviewed it is observed that various frameworks have been advanced to explain and suggest policy and institutional changes to reduce and eliminate the differential treatment of males and females in public and private sector organizations inclusive of higher education however from extant research the limited focus has been placed on examining gender equity in colleges of business a segment of higher education that has significant influence in developing human capital for the public and private sectors the gender equity framework developed from this study helps explain and link the differential treatment of males and females in business colleges to human capital perceptions based on gender entrenched social stratification structures that reinforce patriarchy and established cultural norms and mores figure 2 suggests societal gender inequity is at the heart of creating gender neutrality in all other facets of society therefore societal gender equity is directly correlated to compensation career advancement and leadership furthermore these three elements directly impact gender equity in colleges of business on the other hand societal gender equity is directly related to societal norms culture traditions values and symbols in addition education human capital laws both enforced and unenforced also impact societal gender equity how far can this proposed framework for gender equity go towards helping to understand fair treatment for all members of our society gender inequities are mainstream concerns in the geopolitical arena of institutions and society as a whole however issues surrounding gender equity also are complex vexing and challenging to unravel these challenges are due to entrenched and learned socialization reflected in allocations of authority and resources cultural norms injustices biases and disparities relating to feminism in each culture there are multiple perspectives and theories such as feminist human capital and socialization theories that influence and are influenced by gender equity in the wider society this conceptual framework is vital in contextualizing the impact of societal inequities fueled and nurtured in the formative years in shaping policies and overall treatment of women in institutions of higher education especially colleges of business where there is limited research relating to gender equity methods techniques and modes of inquiry this quantitative approach research utilized the modified athena swan gender equity survey to collect empirical data the targeted population was 1 500 faculty members and administrators from 30 colleges of business in finland jamaica and the united states according to the national center for education statistics 750 public 4year colleges in the united states represent 265 of all 4year higher education institutions in addition finland has 35 public universities and jamaica has two public universities the data for this study were collected in the fall of 2016 colleges of business are selected based on four inclusion criteria accreditation by a national regional or international board such as the association to advance collegiate schools of business and masters granting or higherlevel institutions public universities and university fulltime enrollment of 10000 or more students the targeted population included instructors lecturers senior lecturers tenured or tenuretracked faculty at the assistant associate and full rank professors to complete the surveys a total of 1500 surveys were electronically sent using surveymonkey to faculty members across 25 colleges of business in the united states and four colleges of business in finland and one college in jamaica the surveyed population included administrators to ascertain the relationship of gender equity to compensation career advancement and access to leadership roles for female faculty to collect valid and reliable data the ucl athena swan gender equity survey instrument was modified instrumentation the athena swan gender equity survey developed by the university college of london was selected because it addressed gender equity in stem a field with similar gender distribution characteristics as colleges of business this instrument was used successfully to collect data regarding gender equity from science technology engineering mathematics and medicine professions written permission was obtained from the university college of london to modify the athena swan gender equity survey instrument the survey was divided into eight sections workload flexible working conditionshours appraisals promotion career development workplace culture maternity paternity adoption and paternal leave and demographic data the demographic data addressed gender job role salary range academic rank duration in position work hours education level and geographic location including jamaica finland and united states regions a fivepoint likert scale was used to measure the relationship of gender equity to compensation career advancement and access to leadership roles in colleges of business values on the likert scale range from 15 to assess the relationship of gender equity to compensation career advancement and leadership the likert scale indicated a value of 5 strongly agree 4 agree 3 neutral 2 disagree 1 strongly disagree the sixth option of not applicable was added to the scale for relevance in a few cases this modification was made based on feedback from faculty members who completed the pilot study pilot study pilot research was conducted to increase the validity and reliability of the research and reduce the negative impact of an improperly designed survey instrument on the quality of the final survey results the pilot study was conducted with a representative population of faculty at the rank of instructor lecturerassociatesenior lecturer assistant associate and full professor in addition to the ucl athena swan gender equity survey respondents provided feedback to 12 openended questions relating to survey content and face validity the data from the pilot study questionnaire and the 12 openended questions were analyzed and used to improve the final surveys content and face validity data collection and analysis data collected were analyzed using the ibm spss version 270 software the data analysis includes descriptive statistics exploratory factor analysis independent samples ttest and pearson chisquare test of independence in addition internal consistency of the survey items was conducted to improve the instruments reliability results this section of the paper provides the demographic results followed by the outcomes aligned to the three research questions in total four hundred and sixtysix of the one thousand five hundred faculty members responded to the survey for an overall response rate of 31 from the 466 respondents in finland jamaica and the united states receiving the survey 55 respondents started but did not complete the survey and were dropped from the study this results in a final sample size of 410 and an effective response rate of 273 as shown in table 1 1 based on country 161 of respondents were from finland 73 from jamaica and 644 of the respondents were from the united states furthermore from this sample 122 or 50 participants did not indicate the country location of their business school across the three countries and two continents the data revealed an almost equal number of females and males who responded to the modified athena swan gender equity survey noteworthy is that 45 faculty members chose not to indicate their gender on the survey representing 1098 of the total sample from finland jamaica and the united states these faculty members were not included in any comparisons or analyses related to gender as shown in table 2 446 of females and 444 males responded to the survey the data points to assistant and associate professors making up approximately 34 of the overall participants in the study full professors and college administrators comprised approximately 31 of the respondents furthermore table 2 indicates 66 of the college of business faculty in the sample indicated having permanentopenended contracts compared with 29 employed under fixedtermtemporary employment contracts as reflected in table 2 the majority of respondents were fulltime faculty having a variety of job roles and contract type appointments the time spent in the faculty role despite contract type is outlined in table 3 from the demographic data collected and presented in table 3 we found that 44 of the respondents were in their position for less than five years the data revealed 44 of the respondents were on average still relatively new to their positions additionally over 33 of faculty members surveyed indicated they were between five and twenty years in their positions the data collected also indicate that 43 of faculty members were between 46 and 65 only 38 of respondents were between 26 and 45 years old the demographic data examined provided a snapshot of the spread and impact of gender on various demographic descriptors such as contract type job role caring responsibilities and years in current position the results based on the three research questions are presented in the next section research question 1 to what extent are female faculty members in colleges of business compensated differently than male counterparts for these results compensation data are presented in tables 4 5 and figures 3 4 reflecting selfreported actual compensation earned by business school faculty by country and faculty members perceptions regarding compensation our analysis indicates significant differences exist between how male and female business faculty members in finland and the united states are compensated these research findings strongly support those female faculty members in finland and the united states earn less than males however our findings did not support any significant difference in the actual compensation of male and female business faculty members in jamaica the findings indicate that fewer finnish females than male faculty members earned compensation of more than 55000 euros the top of the salary scale used for comparison additionally regarding female faculty members in the united states sample we found only 222 earned more than 120000year the data we present in table 4 reveal the perceptions of finnish faculty regarding compensation in direct contrast to the actual selfreported salaries of finnish faculty members thus the findings suggest finnish faculty are in effect being inequitably compensated based on selfreported actual salary earned in addition the findings did not support any significant difference between actual and perceived compensation of male and female faculty members in jamaica by comparison to finland hence jamaican business school faculty members actual and perceived salary earned was equitable regardless of gender conversely the data reveal that business school faculty members in the united states perceived inequitable treatment related to salary and access to funding sources for researchscholarship as shown in table 5 the faculty in the united states perceived a difference in salary based on gender this suggests that female faculty in the united states overwhelmingly believe that they are treated inequitably related to salary access to funding for researchtravel and total compensation earned compared to their male counterparts table 6 further elucidates this difference in salary and access to funding for travelresearch based on gender in the united states the data clearly show in table 6 that females in the united states earn less than their male counterparts for doing the same job such inequities demoralize women in the workplace and continue the unfair treatment of faculty members based on gender research question 2 what factors explain differences in the career advancement of female faculty in colleges of business table 7 summarizes the findings of research question two career advancement was measured using the subfactors recognition tenure promotion work flexibility and working parttime career advancement as an overall factor did not indicate any significant difference between male and female faculty members perceived progress in their careers additionally subfactors such as recognition tenure and promotion flexible working and working parttime derived from an exploratory factor analysis using a varimax rotation did not indicate significant differences except for the united states sample as it relates to flexible working hours female faculty in the united states business school indicated that flexible working conditions were inequitable based on gender the findings from the finnish business school sample in table 8 did not indicate a statistically significant difference between career advancement variables equality in treatment regarding promotion access to career development opportunities office space administrative support based on gender conversely business school faculty members in the jamaican sample perceived they were treated unequallyinequitably regarding promotion and receiving administrative support because of their gender the data indicate a significant interaction between gender and the other perceived inequitable conditions faced by faculty in the united states sample table 9 indicates that for career advancement variables such as access to promotion career advancement opportunities equitable office space and administrative support females in the united states sample continue to lag behind their male counterparts irrespective of the number of years on the job only access to promotion and administrative support presented a significant interaction at p 05 level in jamaica no significant difference was found between how male and female finnish faculty access these career advancement variables research question 3 to what extent are leadership positions in colleges of business determined by gender research question three focused on two subfactors genderbiased leadership and equal access to leadership positions derived from an exploratory factor analysis using a varimax rotation this analysis found that genderbiased leadership represented a significant difference in how male and female faculty members in finland jamaica and the united states accessed leadership positions as shown in table 10 only findings from finland and the united states sample indicated a statistically significant difference in equal access by male and female business faculty members to genderbiased leadership the findings relating to perceptions of business faculty regarding other leadership variables are summarized in table 11 table 11 indicates that business school faculty members in finland did not perceive that gender had any statistically significant role in how they accessed leadership opportunities and being involved in decisionmaking within their colleges conversely finnish business school faculty members did perceive that tenurepromotion committees lacked gender balance from the data female faculty perceived fewer females than males are represented on tenurepromotion committees discussion and interpretation of findings the findings are presented and interpreted based on the three research questions that guided the study consistent with the findings regarding the extent to which female faculty members in colleges of business are compensated differently than their male counterparts is borne out in existing literature regarding gender inequities in the united states andfinland the literature we reviewed revealed female faculty in academia continue to be compensated at a lower rate than their male counterparts in finland the data revealed females were compensated at 87 cents to the dollar and in the united states 82 cents to the dollar according to the american association of university women 2020 report according to the statista labor market gender gap index 2021 females in jamaica are compensated 63 cents to the dollar compared to their male counterparts our findings for research question one confirmed what other researchers have advanced that is compensation remains a significant factor impacting gender equity in higher education from this research only data related to the total compensation of faculty members in finland and the united states supported this significant relationshipinteraction between gender and compensation earned conversely the data from the jamaican sample did not support a perceived or actual disparity related to compensation the results from the jamaican sample ran counter to the findings of the world economic forum global gender gap report findings that females are still being compensated at 61 cents to the dollar compared to their male counterparts the perceptions of business faculty members regarding equity in compensation were not explained in the literature reviewed we found that perceptions of inequitable salaries based on gender confirmed the actual selfreported inequitable salary earned by female faculty members in other cases we did not support the findings for example even though finnish faculty members were inequitably compensated based on the selfreported actual compensation they did not perceive gender as having any impact on how they were compensated consequently this research represents a fascinating and important extension based on anecdotal evidence that there is a disparity in how finnish faculty members are compensated this reality can lead to significant social financial and political implications especially for women in colleges of business when compared to jamaica a small developing country there was no statistical difference in the actual or perceived equity in compensation of male and female faculty members on the other hand the findings indicate that faculty members in the united states perceive that gender plays a significant role in compensation this finding was consistent with the literature and supported the actual selfreported compensation data collected in this study current literature placed significant focus on inequity in actual compensation and not on the impact of perceptions regarding compensation of business school faculty members the findings from this research regarding perceptions of equity in compensation will expand earlier research regarding compensation and gender equity although no significant difference existed between compensation and gender for the jamaican sample the findings show that when salaries are negotiated in a highlyunionized system issues of inequity are generally fewer all business faculty in the jamaican sample a public university and the population for this study were compensated based on collective bargaining negotiations hence compensation within jamaicas highly unionized public university system makes it difficult for inequitable compensation to occur at least when faculty are hired document analysis showed emphatically that the university of the west indies the largest public university in jamaica and by extension mona school of business and management the sample for this study hiring practices were guided by a gender mainstreaming policy as a result faculty compensation within the jamaican system is part of collective bargaining and not decided within colleges this collective bargaining practice reduces the likely impact of genderbased compensation at the time of hire these results are in keeping with the literature reviewed in conjunction with research question two the factors that explained the differences in the career advancement of female faculty in colleges of business were recognition tenure and promotion flexible working conditions and working parttime the literature reviewed pointed to gender inequities both in academia and the business world that negatively impacts career advancement of women related to these factors the findings from this study do not support the premise that career advancement on its own was a significant factor being influenced by gender instead the findings reveal that when career advancement subfactors recognition tenure and promotion flexible working hours and working parttime were evaluated against gender they contradicted existing literature the literature indicated that these named factors were essential measures of career advancement that continue to be influenced by gender we found the only exception was the subfactor flexible working hours which presented a significant relationship with gender for the united states furthermore the results on gender perception indicate more females from the united states sample believed they were mistreated regarding issues related to workload perceptions tend to lead to behaviors that may impact an individuals overall performance on the job in keeping with human capital theory hence the findings from this research are essential adding to and extending the body of literature regarding gender equity additionally the findings indicate that male and female perceptions of inequitable treatment based on gender as it relates to promotion and administrative support were significant for some business faculty but not for others in accordance with both feminist and socialization theories for example female faculty members from the jamaican and the united states samples were the only ones perceived to be treated inequitably related to promotion and getting administrative support thus female faculty are still a marginalized population in the united states and jamaica and their perception of disproportionate treatment based on gender may result from their lived experiences again this was in keeping with the tenets of feminist theory additionally perceived inequity by jamaican business faculty may be based on the deeprooted patriarchal culture and socialization patterns of women in the society who are still viewed as being inferior to men in many respects inclusive but not limited to promotion and receiving administrative support the perceptions held of being mistreated in the areas of promotion and getting administrative support are critical components of career advancement that may also be further explained by feminist theory as well as by human capital theory according to socialization and feminist theory how individuals view themselves and others may directly result from the socialization process they have encountered from their formative years through adulthood hence how each individual views themself continues to influence the expectations and their world view and perceptions interestingly for faculty in the united states sample we found a significant relationship between gender and access to administrative support equitable office space career development opportunities and access to promotion additionally united states business school faculty members indicated that they felt unfairly burdened with lowlevel administrative and service work these two factors have proven to be detrimental to their career analysis of survey data does not show a significant relationship between gender and inequities in career advancement for finnish faculty members however according to the european institute for gender equality report females in finland lag behind their male counterparts regarding equitable access to healthcare work power and shared time for caregiving notably female faculty members from the united states and jamaica perceived mistreatment compared to their male peers regarding promotion and administrative support access furthermore female faculty members from the united states perceived they were treated inequitably regarding access to office space and career development opportunities our findings to research question three examining the extent to which leadership positions in colleges of business were determined by gender is interpreted below first the findings indicate that significantly more female business faculty members in all three countries perceive that leadership positions in colleges of business are genderbiased this finding supports both the literature in academia and the business world that gender inequity exists in business school leadership as well as leadership in corporate entities respectively second this study also confirmed findings in the literature that a significant relationship exists between gender and leadership opportunities however what is of interest which deviates from the literature is that significant interactions were not present between gender and equitable access to leadership additionally significantly more female faculty members in the united states sample indicated they noticedobserved others in their college being mistreated because of their gender the fact that more females in the united states sample reported seeing inequitable treatment encountered by faculty because of gender may indicate different historical and social norms in the united states compared to finland and jamaica finally with these strong findings come implications for policy and practice regarding reducing and ultimately eliminating gender inequity within business schools implications of the findings for policy and practice policy implications we found that current literature on gender equity did not focus on business school faculty hence this research sought to fill this gap in the literature additionally examining issues of gender equity utilizing the perceptions of business faculty is not an area of focus in the literature therefore we suggest that the findings from this study add to the general body of research literature on gender equity more importantly the findings of this study extend the discussion of gender equity by accounting for the impact of faculty perceptions of equity through a comparative and multicultural lens using faculty members perceptions of inequitable treatment helps understand why as was found in this study actual data sometimes runs counter to perceived inequities for example even though female faculty members in finland were compensated at lower rates than their male counterparts they perceived no inequitable compensation between male and female faculty members because finland a nordic welfare state is seemingly a more egalitarian society likely faculty would not have perceived any inequity in compensation in contrast faculty from the united states a more individualisticcapitalistic society perceived they are inequitably compensated and in actuality they are additionally in a highly patriarchal society faculty members from jamaica did not perceive they were inequitably compensated this finding was confirmed by selfreported actual salary data provided but contrasted with the world economic forum global gender gap report that indicates that on an overall country basis females are inequitably compensated 61 cents to the dollar compared to males using human capital theory to examine the implications of perceptions regarding faculty compensation and the actual inequities between salaries of male and female faculty members is essential to gender equity research from a human capital theory perspective as olson espoused those who control the power and resources within societies determine how gender issues are viewed and treated therefore if policymakers who make compensation decisions view females as less than males in their ability to get the job done gender inequity will persist furthermore even though females may come to the table with the same human capital the compensation model valued by leadership will often favor male over female faculty according to bowles those who control organization resources are typically those who control power therefore policymakers who more often than not are men need to be educated to have a behavior change and to craft policies that equalize the playing field for females from this study we found that more males in the study sample earned higher compensation this unequal distribution of compensation based on the postulate of bowles and kerbo will likely lead to the unequal distribution of power and likely determine how females are treated viewed and positioned in society to deconstruct the stereotypical view that men are generally destined to earn more than women based on expected societal norms one must examine how men and women are socialized in their formative years this socialization process and practice generally decide how males and females perceive themselves and ultimately treat others implications for practice except for working flexibly an important practice impacting gender equity in the united states career advancement was not deemed a significant factor explaining the differences in how male and female faculty members progress in their profession based on these results we imply that generally business faculty across these distinct cultures of finland jamaica and the united states do not perceive their progression in their career being impacted by inequity in tenure and promotion recognition for their work and working parttime the findings suggest that working flexibly is a significant factor impacting the career advancement of female faculty in the united states these findings suggest that it is incumbent on legislators and policymakers at the national and university level to place more effort on eliminating perceived and actual inequities in compensation across these three countries additionally accommodating working flexibility should become more equitable especially as more females than males participate in caregiving roles equitable access to leadership positions continues to be a critical factor advanced by many in the literature regarding male and female faculty the data obtained from business faculty in finland jamaica and the united states are emphatic that leadership positions in business schools are gendered in favor of males over females our findings further indicate that more male than female faculty members is in leadership positions in business schools across the three countries the aacsb report supports this finding business school data guide report and other literature reviewed this finding implies that even though in finland jamaica and the united states legislation and policies have been enacted to assure females have equitable access to jobs and opportunities they still lag behind males based on their human capital we suggest that policy and practice implications implore policymakerslegislators at the country and university level to reexamine current equal employment opportunity mandates and determine necessary changes that will positively impact female business faculty access to leadership roles equitable compensation and particular career advancement opportunities crafting policies that lead to acceptable practices that focus on providing opportunities for more females to access leadership positions will be a step in the right direction more females in leadership and policymaking positions provide both a real and psychological boost to females coming through the pipeline conclusion conclusively in this study we set out to examine the relationship between gender equity and compensation career advancement and leadership we found there were powerful connections between gender and actual compensation for finland and the united states however no significant relationship existed between gender and compensation for jamaica due to hiring policies guided by a collective bargaining unionized environment in addition there was no significant difference between gender and career advancement for all three countries furthermore our study confirmed genderbased leadership roles continue to significantly influence hiring practices in business schools where more males control senior leadership positions are tenured or tenuretracked full or parttime faculty and graduate teaching assistants compared to females gender inequity persists in the wider society its impact in businesses colleges is farreaching as these business schools have the enviable task of preparing students who will likely be the business leaders of tomorrow or future faculty members these research findings suggest the need for a strong focus in terms of policy and practice for fixing or providing equity for current gender inequities this would require placing greater emphasis on societal norms values mores and beliefs that shape each individual hence the study posits a conceptual framework that places focus on deconstructing societal perceptions from the formative years that women are less than or unequal to men however trying to make meaningful change after the formative years where deeply rooted normed behaviors have been reinforced is difficult if not impossible in engendering sustainable changes in attitudes and behaviors by women about themselves and others regarding their place in society the deconstruction of entrenched societal and cultural norms must begin in the formative years for both males and females to assure that behavioral changes are sustained by accepting equity and equality for all members of society additionally the findings of our study indicate actual and perceived unequal compensation by gender should inform legislation educational policies curricula and other measures that seek to change cultural institutional and personal perceptions regarding gender equity finally we want women worldwide to perceive and experience fairness in how they are compensated promoted and given access to leadership roles this way balancing the scale of gender equity will be achieved

this paper examines the relevance of gender equity to faculty compensation career advancement and access to leadership roles in selected business schools in finland jamaica and the united states these three countries reflect distinct cultural political economic and societal structures and views regarding gender equity anchored by feminist human capital and socialization theories we present the perspectives of both male and female business school faculty through cultural economic and societal constructs a total of 410 business faculty members across 30 colleges in finland jamaica and the united states completed the modified athena swan gender equity survey from this research a conceptual framework was developed to help higher education administrators and faculty members contextualize the oftendissimilar experiences of business school faculty from a multicultural perspective the findings confirm that female faculty in business colleges continue to lag in perceived and actual compensation and access to opportunities to succeed in business schools compared to males additionally the findings support the further examination of the dichotomous relationship between perceived and actual gender inequities encountered by female faculty in business schools these inequitable treatments continue to reflect even with positive societal shifts a distinctly patriarchal leadership career advancement and compensation system in business schools often regardless of cultural norms and mores our findings add to the organizational and gender studies literature by proposing a balancing of the scales for gender equity in business schools from a multicountry perspective

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background social relationships and health social inequalities in health are universally recognised as a significant public health problem 1 the who conceptual framework for action on the social determinants of health postulates that structural determinants including the socioeconomic position of individuals shape health outcomes through the material psychosocial and biological factors according to this framework psychosocial factors include social relationships with social cohesion and social capital seen as cutting across the open access correspondence structural and intermediary determinants to influence health inequalities 2 in the uk tackling health inequalities is an important national strategy the publication of the white paper healthy lives healthy people 3 in response to the marmot review 4 led to fundamental legislative change in the governments approach to tackling the broader structural determinants of health this change in legislation led to the health and social care act 5 mandating health bodies including public health england to reduce health inequalities 6 however whilst material and behavioural pathways between socioeconomic position and health have been studied extensively few studies have explored the contribution of social relationships to social gradients in health social relationships are an umbrella term for the social ties individuals have with others 7 and include aspects such as but not restricted to social support social networks social capital and social participation they can be operationalised using either structural or functional social relationship measures and include aspects such as but not restricted to social support social networks social capital and social participation structural social relationship measures refer to the quantitative part of social relationships for example marital status social network size or isolation 8 functional measures refer to the qualitative aspect of social relationships for example social support and loneliness 8 social relationships can also be operationalised at the individual and community level for example social support loneliness and isolation can be viewed as individual level social relationships whereas social participation social cohesion and social capital are commonly measured at community level the importance of social relationships for health and wellbeing is well established 79 a metaanalysis by holtlunstad et al 9 concluded that the influence of social relationships on mortality risk is comparable in magnitude to the impact of other wellknown risk factors such as obesity and healthcompromising behaviours more unsatisfactory social relationships have also been linked to an increased incidence of coronary heart disease and stroke 10 higher levels of inflammatory markers 11 poorer selfrated oral health and oralhealth related quality of life 12 depression 13 cognitive decline 14 15 16 and altered host susceptibility to disease due to the effect on immune function and neuroendocrine responses 81718 evidence of the mediating and moderating role of social relationships in explaining health inequalities despite the vast literature on the importance of social relationships for health evidence regarding the role of social relationships in explaining health inequalities is limited and results have been contradictory 1920 evidence suggests potential interactions between markers of socioeconomic position and social relationships and their collective impact on social inequalities in health several previous studies assessed whether social relationships can weaken or strengthen the associations between socioeconomic position and health but results have been highly variable 21 22 23 24 25 26 to date there has been no comprehensive review of the literature on the role of social relationships in mediating or moderating health inequalities existing reviews have focused on the role of social capital 27 28 29 carlson and chamberlain 27 and vyncke et al 29 reviewed the role of neighbourhoodlevel social capital in explaining social inequalities in health vyncke et al 29 limited the population group to children and adolescents and carlson and chamberlain 27 focused on civic trust alone similarly uphoff et al 28 only examined whether social capital moderates socioeconomic inequalities in health research aim this systematic review aims to assess and synthesise the evidence on the role of social relationships in the association between socioeconomic position and health the main objectives are 1 to assess the evidence for the mediating role of social relationships in the association between socioeconomic position and health 2 to assess the evidence for the moderating role of social relationships in the association between socioeconomic position and health methodology protocol and registration this protocol is registered with prospero and has been reported according to the preferred reporting items for systematic reviews and metaanalyses protocols 30 study eligibility criteria participants individuals from any population group and of all ages will be includedthere will be no age restrictions or cutoffs for including or excluding studies in this review individuals with any physical or mental health condition will also be included study design the review will include any interventional or observational study that assesses the role of social relationships in mediating or moderating health inequalities studies need to have quantified the contribution of social relationships to the association between socioeconomic position and health or presented interaction effects or stratified results for different levels of social relationships studies will be included if they examine the mediating or moderating role of at least one indicator of social relationships in the association between socioeconomic position and health the search will include peerreviewed articles as well as grey literature available from the databases specified below the only restrictions in terms of publication type will be for review articles opinion pieces and theoretical articles which will be excluded studies will be excluded if they only adjusted for socioeconomic position rather than test for the mediating or moderating role of social relationships in explaining health inequalities outcomes an earlier scoping search revealed that there are not many studies that have examined the mediating and moderating role of social relationships in explaining social inequalities in health as such this review will include studies that cover a wide range of subjective or objective measures of mental and physical health when assessing health inequalities outcome measures will include but will not be limited to mortality coronary heart disease stroke immune response selfrated health healthrelated quality of life depression cognitive decline and measures of oral health the inclusion and exclusion criteria will not be based on the type of outcome measure used however these will be recorded when extracting the data exposures the exposures of interest are socioeconomic position and social relationships the review will focus on the combined impact of these exposures ie studies will only be included if they explored whether social relationships mediated or moderated the association between socioeconomic position and health socioeconomic position summarises an individuals position within the social hierarchy and refers to their material and social resources 2 studies will not be excluded based on the type of the socioeconomic variable used any measure of socioeconomic position will be included such as occupational status educational level income or household wealth as well as proxy measures such as housing tenure or car ownership where the indicators mentioned above are not available there is no universally agreedupon definition of what constitutes social relationships therefore the search strategy intentionally included terms that refer to the degree of connection individuals have with others these included but are not limited to social connectedness social support social networks engagement sociability social attachments social capital and social integrationkeeping the definition of social relationships broad will enable identifying studies that differentiate between structural and functional aspects of social relationships studies will not be excluded based on the type reliability and validity of the social relationship measure used any article published in any language will be retrieved no date restrictions will be applied to the search strategy and databases will be searched from the earliest date of entry until 10th june 2021 search strategy an electronic search will be carried out to identify all relevant studies from the following databases medline embase classic embase and psycinfo search terms include terms relating to social relationships socioeconomic position and health inequalities specific health outcomes will not be included in the search strategy as any health outcome will be considered various tools such as boolean operators truncation and proximity indicators will be used to ensure a comprehensive search that identifies all relevant articles the search strategy was developed by nk and js and peer reviewed by js ka and dm using the peer review of electronic search strategies checklist 31 reference lists of all relevant fulltext papers will be screened to retrieve additional articles not identified through the database search the study selection process will be summarised in a prisma flowchart 32 study selection all relevant articles retrieved from the database searches will be stored in the reference manager mendeley 33 fulltext articles will be exported to rayyan qcri 34 after removal of duplicates two reviewers will use rayyan qcri 34 to independently screen titles and abstracts for eligibility the ucl linking service will be used to retrieve full texts of relevant articles any disagreements regarding the inclusion of papers will be resolved through discussions any remaining unresolved disputes following this process will go through a tiebreak decision from an external reviewer not involved in the review process data extraction a data extraction form will be developed and piloted using a sample of eligible studies the piloting process will ensure reliability in the interpretation and use of the inclusion criteria upon finalisation of the data extraction form the reviewers will extract the data and reasons for exclusion will be listed any discrepancies will be resolved through consensus meetings the reviewers will extract data regarding key elements of each study including it is expected that outcome measures will be both continuouswith results presented either as standardised or unstandardised beta coefficients or categoricalwith results presented as odds ratios relative risks or hazard ratios • synthesis it is anticipated that the eligible studies to be included in the review will be highly variable with regards to populations settings study design and outcomes it is further anticipated that results across studies will take various statistical formsthese results will be converted to a common effect metric if feasible ie where heterogeneity is low to moderate a randomeffects metaanalysis will then be used to pool these estimates in a forest plot forest plots will be presented separately by study design for studies that assess mediation and similarly for studies that assess moderation where information is missing to calculate a common effect metric additional information will be requested through contacting the authors directly subgroup analysis or metaregression will be carried out to assess sources of clinical and methodological heterogeneity selected a priori social relationship type ie structural or functional socioeconomic position marker health outcome the higgins thompson i 2 test will assist in ascertaining whether heterogeneity exists provided there are at least ten studies included in the metaanalysis the i 2 test statistic can be imprecise for a small number of studies for example a metaanalysis with seven or less studies 35 the i 2 statistic will need to be within a recommended threshold preferably 60 36 a funnel plot will be used to assess for publication bias the economic and social research council methods programme guidelines 37 will be used to guide the synthesis and will allow identification of any sources of heterogeneity if the studies are too heterogeneous ie substantial to considerable heterogeneity whereby i 2 statistic 60 36 a narrative synthesis of the data will be presented by health outcomes and grouped by 1 mediation analyses a selfrated health b mortality chronic disease and physical function c depression and mental health 2 moderation analyses a selfrated health b mortality chronic disease and physical function c depression and mental health if a metaanalysis is not feasible the results will be presented in a narrative synthesis with effect direction plots detailed descriptive tables will be presented in a supplementary file results from studies will be reported as either positive null findings mixed findings or negative findings studies will then be further ordered by risk of bias using colourcoding ie low moderate and high bias risk of bias observational studies will be quality assessed using a modified version of the newcastleottawa quality assessment scale 38 assessments of these studies will include representativeness of participants statistical methods implemented including identification of potential confounders handling of missing data attrition in longitudinal studies how exposures and outcomes were measured and any significant limitations of the study the revised cochrane riskofbias tool rob 2 39 will be used to quality assess any randomised trials included in the review assessments of these studies will address bias in the randomisation process the selection of results reported the handling of missing data and bias due to failure of reporting on deviations from intended interventions nonrandomised trials will be risk assessed using the risk of bias in nonrandomized studies of interventions tool assessments of these studies will address confounding selection bias information bias and reporting bias 40 reporting to allow for transparency and reproducibility of the findings the methods and results of this systematic review will be reported according to the preferred reporting items for systematic reviews and metaanalysis guidelines 32 timeline for systematic review it is anticipated that data extraction will start from 31st june 2021 and a draft manuscript will be completed by january 2022 discussion the quality and quantity of social relationships impact mortality morbidity and mental health 78 public health england has acknowledged social isolation and social inequality as being related to poor health outcomes 41 therefore this systematic review will examine the link between social relationships and health inequalities the indirect link between socioeconomic position and health via social relationships will be investigated with attention being paid to the mechanisms identifiedwhether social relationships mediate or moderate the association between socioeconomic position and health the strengths and limitations of the evidence will be considered and findings will be discussed in context with related reviews the results of the review will summarise the existing evidence of the impact of social relationships on health inequalities and identify gaps in knowledge where further research is required it is expected that the findings will be useful for the development of policies aiming to reduce social inequalities in health • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from abbreviations who world health organisation prospero international prospective register of systematic reviews prisma preferred reporting items for systematic reviews and metaanalyses additional file 1 research checklist additional file 2 table 1 search terms additional file 3 tools and techniques for search strategy competing interests the authors declare that they have no competing interests

introduction explanations for health inequalities include material behavioural and psychosocial pathways social relationships are an important determinant of health and research has consistently found that a lack of support networks may diminish favourable health outcomes there is some evidence that social network structures partly shaped by socioeconomic factors contribute to health inequalities this protocol will summarise the systematic review processthe systematic review will be reported according to the preferred reporting items for systematic reviews and metaanalyses guidelines an electronic database search of medline embase classic embase and psychinfo using the ovidsp platform will be undertaken databases will be searched from the earliest date of entry until 10 june 2022 articles that have quantitatively assessed the role of social relationships in mediating or moderating health inequalities will be included and any health outcome mentalphysical will be considered the database search will be supplemented by reference list screening of all relevant fulltext articles identified through the search two independent reviewers will be responsible for screening of articles data extraction and assessment of bias observational studies will be risk assessed for bias using a modified version of the newcastleottawa quality assessment scale and intervention studies will be assessed using the revised cochrane riskofbias tool it is anticipated that the eligible studies will be highly variable therefore a metaanalysis will only be considered if the available data of the selected studies are similar if the studies are too heterogeneous a narrative synthesis of the extracted data will be presentedthe results of the systematic review will examine the link between social relationships and health inequalities the findings of the review will identify gaps in knowledge where further research is needed

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method ipa is an idiographic approach that can explore the rich idiosyncratic detail of individuals experiences and how they make sense of them it takes the experiences of individuals as its data but acknowledges that subjective experiences are always interpretations and that the emic interpretations of participants are not the only way to understand the phenomena being studied data collection the first author conducted semistructured interviews with each participant individually in private locations agreed with each participant the interview schedule covered seven broad areas each introduced with an open question and supplemented by additional prompts interviews began by asking the participant to speak about who they are and their background they were then asked about their perspective on life and the world with prompts eliciting the sources of meaning purpose and value in their lives next participants were asked to tell the interviewer about god and their religious or spiritual activities participants were then asked to describe specific experiences of god in detail the interview ended by exploring whether the participant thought their beliefs had changed during their lifetime and by giving them an opportunity to discuss anything they had not yet mentioned but felt was relevant or important the interviews ranged from 44 to 93 minutes in length with a mean of 57 minutes participants were briefed prior to their interviews and debriefed afterwards analytical process audio recordings of each interview were transcribed and imported into nvivo 11 before being analyzed by the first author in consultation with the other authors each transcript was annotated with initial comments and reflections before coding coding was inductive and iterative first examining each case individually and then reexamining them in light of each other emergent themes were consolidated and those found in at least half the accounts were identified as recurrent subthemes and grouped conceptually into superordinate themes this process was extensive and exhaustive with the themes repeatedly refined as they were rigorously checked against the data and discussed by the research team writing up qualitative research is an integral part of the analysis and our understanding of each theme evolved during this period as we reflexively tested our interpretations of the data memos were used throughout data collection and analysis to document this process the account presented here is an interpretative account of the participants experiences and meaningmaking processes based upon the complete data the extracts presented within it were chosen to illustrate the themes and show key aspects of convergence and divergence within the participants experiences researcher backgrounds the research team consisted of the first author who conducted the interviews and was the principal analyst and a diverse supervisory team the first author was raised as an evangelical christian and has degrees in theology and the psychology of religion but now identifies as not religious the supervisory team included a practicing lutheran a humanist celebrant and a mindfulness practitioner we were committed to engaging with the participants experiences in their own terms putting aside assumptions as much as possible we were constantly alert to the possible influence of our own experiences and beliefs on the analysis and the diversity of the team was particularly useful in this regard it also helped deepen the analysis and clarify the findings as the mixture of insider and outsider perspectives ensured many different possibilities were considered we are confident the findings are strongly grounded in the data because possible interpretations were always rigorously tested against it and many alternative ways of framing the data were considered before reaching the final analysis presented here ethics ethical approval for the study was granted by the universitys ethics committee and informed consent was received from both the church leadership and each participant we clearly explained to participants that they did not need to discuss anything that made them uncomfortable however all the participants chose to share highly personal accounts of their lives to protect the participants anonymity the account presented here describes only minimal personal information about them but the wider contexts of each participants life were considered in the analysis debriefing provided the opportunity to address any distress or concerns that might have arisen during the interviews but the participants primarily showed curiosity about the research and expressed gratitude for the opportunity to take part results eleven recurrent subthemes each found within the accounts of at least half the participants were developed and organized into two superordinate themes knowing god and living in the world knowing god explores the intimate relationships the participants experienced with god the ways they made sense of their experiences and the certainty of their convictions living in the world explores the tensions of living life in but not of a world that is not christian it examines the multifaceted ways their faith affected and was affected by a range of social and cultural influences each subtheme occurred in the accounts of all five participants except studying scripture to understand god which was not found in jennys interview these themes were complementary and subthemes often had connections to many others responding to challenging situations some of them were struggling in their failings and their fallenness and therefore my preaching became very much about trying to affirm people in who they are finding meaning and purpose there is something more than whats in it for me in the sense of the bigger picture which certainly adds purpose faith affects everything gods the center… everything flows down from that theme knowing god all five participants described experiencing a loving and nurturing relationship with god they considered their relationships with god and the fact that they knew god personally a central and defining feature of their christian identities and the most important thing in their lives being christian rather than being baptist was the cornerstone of their personal and communal identities there were many similarities between the relationships the participants had with god but also some individual differences in how they experienced and made sense of their lives and faith ian described how theres a god who i know and have a personal relationship with… hes probably more daddy rather than god karens relationship with god shared the intimacy of ians and she declared joyously that jesus is my home boy he was a friend who was always there for her somebody who she thought was a lot like us but um just more hes just more the participants described knowing god in their lives through a range of experiences and both prayer and worship made them feel close to god the participants prayed in a variety of different ways including formal intercessions during religious services and more informal prayers at other times jenny summed up her attitude to prayer by saying if i see something i pray about it and if i need to do something… i just… pray… anywhere this approach was common to all five participants and shows the importance they placed upon gods guidance their belief that god acts in the world and the intimacy of their relationship with god the participants believed god was interested in every aspect of their lives and they could approach him at any time and without formality they experienced god as a daily companion whom they could always talk to despite this intimacy their conversations with god were usually onesided and only ian reported an experience of god speaking to him audibly the participants frequently requested guidance or divine intervention in situations but they reported the outcomes of such intercessions were mixed their memories of positive outcomes appeared most salient and these seemed to mitigate the potential effects of negative outcomes on their faith gareth summarized this attitude saying although there are many times when prayers dont get answered as you would wish and things dont go according to plan the fact that there are enough times when things have worked out… means you can make sense of the disappointments by recognizing that there have been many times when those things have happened musical worship was also an important part of the participants lives and they described how it created a more intimate and emotional connection between them and god than prayer like prayer this worship was not limited to church services the participants regularly played christian music in their cars homes and other contexts karen described how during worship youre communicating directly with god… when you pray you come to god but when you worship god comes to you… it does feel like you have such a clear connection with god when you are really enjoying worship the participants found joy in their relationship with god which encouraged them to invest in it and the experience of clarity made them confident their faith was true the bible played an important role in the lives of all five participants they considered it to be gods revelation to mankind and they studied scripture to understand what god was like and what god wanted from them ian summarized this position saying the bible would be the main way i think i know god… he is revealed in his word despite the importance of their personal experiences the bible had central importance in their lives because it helped them make sense of their experiences as karen said everything that we need to know how to live to become closer to him i think its all in the bible only jenny who was dyslexic and struggled to read and study did not speak about reading the bible for herselfbut she still valued its contents and learned about it through sermons and conversations with other christians for the participants the bible was both a source of information about god and a way god communicated with them the participants described often having tangible feelings of gods presence and attributed certain thoughts to his inspiration and guidance these experiences played a crucial role in affirming and reinforcing their beliefs about god and their relationship with him the participants feelings of gods presence were somewhat ineffable but tangible somatic and emotional ian described them as a really really ecstatic but in control happy feelingalmost like the nice warm glow you get if youve had one drink too many… its warm fuzzy… hard to describe these feelings of joy affection and gratitude were experienced by all the participants in a wide range of circumstances and they could both affirm and stimulate faith gareth described how his conversion at a billy graham rally involved such a bodily response after the sermon during the altar call gareths head changed i felt … tingles all the rest of it… and that was what converted me believing he had experienced gods touch provided a powerful affirmation that god was real active and cared about him the participants also spoke about just knowing that some of their thoughts were from god these inspired thoughts could take many forms including recalling bible verses but they all involved a conviction they were from god and should be heeded ian described this feeling as a sense of certainty a sense of intuition or maybe word of knowledge might be a way to describe it despite the conviction they often felt the participants were frequently hesitant to ascribe these thoughts to divine inspiration and did not do so uncritically they sought the input of trusted others and compared their thoughts to scripture for confirmation jenny described this process saying i dont feel i hear god that much but i do because people say to me yeah thats from god… i need a second opinion before before i realize its god gareth also acknowledged the potential to be wrong about what god was saying in a situation attributing such errors to the need for god to speak through the filters and the impressions of our minds and because of that we sometimes will get it wrong this lack of certainty and clarity about particular instances of god speaking helps explain the iterative way that their relationships with god and beliefs developed they all believed they experienced gods touch and guidance but this had an inherent ambiguity that required them to integrate many different experiences into a more coherent set of beliefs the participants also described how they saw gods activity in the events of their lives these experiences nurtured and reinforced their beliefs about god particularly the beliefs that he was real and cared about them gareth described how one of the things that has sustained that belief over the years has been a remarkable coming together of events some would call them coincidences i would call them answers to prayer all five participants told stories about unlikely but meaningful circumstances that helped shape their lives these ambiguous events included people finding jobs after long searches and medical issues being less severe than they might have been for the participants these experiences demonstrated that god answered their prayers and kept his promises helping them have faith that they knew gods character and that they were his people karen highlighted the importance of these experiences of divine intervention for the participants reporting she regularly told people the reason she knew god was real because she had experienced god in my life even before i was a christian many of the events that the participants described were relatively mundane but they also included the apparently miraculous ian reported the most dramatic of these experiences saying that gods protected me supernaturally a couple of times… there was a sense you know quite miraculouslygods protecting us the story he told to illustrate this involved an angry confrontation with a soldier wielding a grenade and the unexpected intervention of a bystander who defused the situation for ian this was a clear example of divine intervention although a more mundane interpretation is also possible and the extent to which participants were comfortable acknowledging the ambiguity of the situations varied these experiences and retelling them to others created a sense that the participants lived lives in which god was an active part the participants relationships with god although loving and nurturing also included negative emotions and disagreements the participants described experiencing god asking them to do things they did not want to do as well as times when god did not do what they wanted for example karen discussed how she could be a little hardened or stubborn… he might be giving me little signals do this do this and im like i dont want to do that these arguments and disagreements with god did not appear to diminish the bond that the participants experience with him but instead seemed to ultimately strengthen their faith in god when they experienced positive outcomes for example when a serious relationship karen was in ended she was angry and thought god had let her down but a couple of years later i met my husband and i was like oh i get it now… im sorry lord you were working it out for me and i got mad at you im really sorry the language used to describe these experiences demonstrated both the intimacy and vibrancy of the relationships the participants believed they knew god intimately and with certainty they related to him like a close friend whom they trusted the participants diverse experiences of god in their lives affirmed their faith and provided a bulwark against doubts and tribulations theme living in the world the personal and dynamic relationships with god that each participant reported experiencing did not occur in isolation the participants described living lives that were varied and social involving active engagement with all aspects of modern life the participants interactions with other people and involvement in a wide range of situations influenced how they experienced god and life in various ways other christians appeared to play a crucial role in supporting and developing the participants faith and relation ships with god the participants discussed being members of multiple churches at different stages of their lives and these communities influenced what they believed and did close friendships and romantic relationships with other christians were particularly important to the participants providing support and affirming their faith in their daily lives god had a central role within their family lives and teaching their children about their faith encouraged them to live out their own beliefs havir summed this up reflecting that it is so important to steer them in the right direction… the way jesus wants us to lead our lives i think those truths have been drummed home a lot more because we want the kids to be like that living with other christians helped the participants keep god at the center of their lives and develop into the people that they wanted to become they viewed these influences as positive blessings understanding processes as supportive of their efforts to develop into the people that they wanted to become gareths descriptions of his evolving faith clearly showed the importance of other christians in his life he described how before he became a christian persistent friends at university took me to church on sunday nights… id never experienced anything like that… to encounter this whole generational thing that young people could believe this and live this was was significant the passion and commitment of his friends showed gareth a type of christianity he had never encountered before offering an alternative way of understanding the world that intrigued him his experiences of them led him to attend the service that changed his life and they helped him make sense of his experiences afterwards after he graduated gareth was surrounded by christians with different beliefs and he attributed his own beliefs becoming more inclusive and liberal to their influence reflecting on his experiences he said youre not conscious at times of the subtle changes in your thinking that are taking place… i can look back and think of some… wonderful prayers and preaching… that contribute d to a reformation of the theological mindset and approach both the explicit teaching and the implicit values of the participants communities appeared to influence how they perceived themselves god and the wider world the participants closest family and friends shared their beliefs but they lived in a society that increasingly did not their experiences and beliefs were clearly also influenced by the wider society around them in various ways encounters with behaviors and beliefs that conflicted with their own could lead to the participants altering their beliefs or becoming more convinced of them havir who went through an extended period of more nominal faith despite being raised in a christian family described how a relationship with a hindu girlfriend caused him to decide what he believed and what he wanted from life he started comparing… really kind of searching comparing you know my beliefs my faith with that of someone… with a polytheistic background and faith his girlfriend presented him with the possibility of an alternative way of life and made havir need to choose how he wanted to raise his future family this reflection was the catalyst for a profound change in the importance he placed on his religion and how he lived his life the participants encounters with other perspectives sometimes caused them to change some of their beliefs for example ian described how his beliefs about homosexuality had shifted over the previous decade and he identified friendships with gay men as a key catalyst for that change he suggested that the liberal attitudes of wider british society may have influenced his beliefs on the issue and this caused tension for him he reflected that there is a worry… about just you know the church following societys line for the participants god and the bible were supposed to determine what was right and they were supposed to be different even when it carried a cost however their interactions with others sometimes caused them to question aspects of their faith and this process could lead to them either altering their beliefs or becoming more convinced of them experiencing challenging situations and events often drew the participants closer to god who provided security and comfort in times of crisis jenny had experienced many traumatic experiences including severe physical illness poverty and abuse she described how god was a light… and he helps you in difficult times she also viewed her suffering as having purpose and value because it helped her get to the point where i had to rely on god um i didnt do that before it took two years in this horrible place i had to learn stuff like the other participants she looked for positives in her experiences of adversity and gave god credit for the situations not being even worse the process was neither quick nor easy but she learned to turn to god in her suffering and the comfort she found strengthened her relationship with god the participants spent considerable amounts of time helping others and they described how these relationships made their lives more meaningful jenny described how helping others gave meaning to the many struggles she had been through she now worked with a churchbased charity and said she had come to the conclusion that… if i wasnt bullied and i didnt go through what i did i wouldnt have the real experience to tell people… god has changed… the challenging bits to ok positives the participants faith helped them find meaning and purpose both in their ongoing lives and in their pasts they believed they were called by god to do what they were doing and this enabled them to view their daily activities as sacred and significant the belief that what they were doing truly mattered helped transform mundane activities into something more and nurtured their sense of living lives that were sacred and meaningful challenging encounters or events sometimes posed difficult questions for the participants and required them to reconcile their beliefs with the world they experienced for example the participants sometimes found suffering and pain theologically challenging to reconcile with their conception of a loving and omnipotent god gareth described how seeing the pastoral needs of others as they lived through difficult situations led to him softening his doctrinal beliefs compassion led him to rethink his theology because i need to be able to affirm these people as legitimate bona fide members of my congregation… they need to be affirmed… therefore my preaching became very much about trying to affirm people in who they are these changes did not stop the participants from being christian but they altered what they understood being christian to mean and they viewed these changes as their faith maturing challenging circumstances sometimes functioned as catalysts for change in the participants lives leading to significant and lasting changes in their beliefs and behaviors the participants believed the calling to live their lives for god was an inherent part of being a christian and that their actions and choices had eternal significance being christian was a central facet of their personal identities and lives ian described how his faith gave him a sense of the bigger picture which certainly adds purpose havir went further saying that he believed that without god and an eternal afterlife things would be futile and meaningless the participants cared deeply about other people but their faith altered their perspectives and affected their choices it framed how they understood themselves and the world for these five participants their relationships with god and christian faith affected their entire lives their faith influenced the activities they did the choices they made and the relationships they had havir summed this up saying gods the center thats it really… everything flows down from that the boundary between the secular and the sacred was at least blurred if not meaningless in the participants lives because they included god in every situation and interpreted events through their faith ian described how worship is all our life and everything that we do and sacrifice to god and gareth noted he could not separate faith from life because to me they are entwined these participants faith influenced everything they did they experienced god as a supporting presence in every area of their lives in ians words their faith was not a crutch but was more like a mountaineers poleit helps you but because of it you can climb mountains that you wouldnt otherwise climb discussion this study used ipa to explore the lived experiences of five members of a baptist church in britain the participants described experiencing relationships with god similar to their relationships with other humans these relationships between the participants and god were a fundamental part of their lived experiences and affected all aspects of their lives they believed they knew god intimately and described living in a world of which god was an active and integral part the participants relationships with other people their life choices and their overall wellbeing were all connected to and rooted in their belief that they knew god as a living presence in their lives without understanding the participants faith and the relationships they experienced with god any understanding of the participants lives and behavior would be incomplete living in a sacred world the experiences that participants attributed to god were diverse and there were not clear boundaries between what the participants considered sacred and the rest of their lives any experience could encourage them to pray and they could perceive any situation as the work of god these findings echo ammermans work in the united states that found religion often permeates social boundaries to both influence and be influenced by interactions in other spheres of individuals lives as taylor notes religious beliefs are often not something extra that is added on to a secular life for many people religious identities and beliefs are an integral part of how they understand themselves and the world affecting many aspects of their lived experiences the participants faith provided the interpretative framework for their whole lives the participants experiences of such a sacralized world are unlikely to be shared by all christians more nominal christians who do not frequently attend church or participate in other religious practices probably do not have similar relationships with god or the same experience of living in a world where god is active as these participants havirs experiences demonstrate how someone can understand being a christian in disparate ways at different points in their lives in contrast to his more recent experiences for many years his faith had little influence on his life this fits with the idea that each individual believer constructs what it means to be a christian out of the many cultural resources they have available and these personal meaning systems do not always give a prominent place to god or broader existential ideas how people understand themselves and the world changes during their lives and significant changes in individuals worldviews can occur more than once the idiosyncratic blending of diverse beliefs and practices by each individual means that care must be taken when using a fractionating approach to study specific religious phenomena the combined effects of the diverse elements of an individuals meaning system may be greater than the sum of their individual practices and beliefs both prayer and worship were important to the participants but it was the combination of the two practices with their broader beliefs and social contexts that sustained the participants faith and guided their actions god was an integrating focus and an intensive concern for participants with extensive effects throughout their life it is clearly important to study individual religious phenomena but how these phenomena are experienced the meaning ascribed to them and the effects they have may both influence and be influenced by a wide range of other beliefs and related experiences constructing a sacred world the importance of socialization in the formation and development of religious beliefs is wellestablished and the influence of social and cultural factors was clear in the accounts of all the participants most people accept the existential interpretations and explanations of those they trust though as this study shows they do not always do so uncritically and experiences may cause them to question or reject such explanations god was a real and important part of the social reality the participants shared and their faith in him had widereaching consequences understanding their lives and actions without recognizing the role god played in them is impossible the participants both as individuals and a group interpreted events in ways consistent with and reinforcing their shared worldview ambiguous events were often attributed to divine intervention and the encouragement and support of trusted others helped overcome any doubts they experienced their frequent declarations and affirmations of the truth of their relationships with god helped create their social reality the cumulative effects of many experiences also made each of them more persuasive than they would have been in isolation repeatedly reinforcing their trust in god the participants world became sacred through their communal practices and expressions of faith the interactions of different influences both christian and nonchristian contributed to the idiosyncratic beliefs of each participant which sometimes were incongruent or theologically incorrect as lee argues people often draw upon a range of existential resources to help them make sense of their own lives and experiences the differences between participants experiences should not be overlooked as they are crucial to under standing their beliefs and behaviors the five participants were part of the same church and espoused the same doctrinal beliefs but they had very different lived experiences that influenced their physical and psychological lives the accounts of the participants support viewing beliefs about god the self and the world as part of a cohesive idiosyncratic model of the world that each person develops during their life in response to their experiences experiencing a relationship with god the experience of knowing god directly was of central importance to each participant and provided the bedrock for the participants faith and beliefs the relationships between the participants and god developed over time and like most relationships had both negative and positive features the participants described their relationships with god as being like a relationship with a close friend or family member and it is plausible that this similarity to other relationships reinforced their belief that it was with a real and independent being god for these participants was a nonhuman supernatural agent whom they seemingly perceived and experienced using very similar cognitive mechanisms to other agents in the participants worlds they found his existence not only plausible but actually indisputable because of the combination of their frequent personal experiences and the supporting experiences of those around them the findings of this study do not speak to the ultimate truth or otherwise of the participants interpretations of their experiences and we wish to note the data are consistent with a range of possibilities these include both that the participants are genuinely experiencing something beyond themselves and the view that religious experiences are byproducts of our evolved cognitive architecture cultural contexts and ambiguous sensory experiences the participants described god as a source of personal comfort and security they experienced god as a reliable powerful and loving presence in their lives their differing childhood experiences and the comfort they derived from their relationships with god are consistent with the theory that god can function as either a surrogate or complementa ry attachment figure for different religious individuals the participants were grateful they experienced god as a supportive presence in their lives and they shared their faith with others because they wanted them to benefit from the same experiences the accounts of how the participants learned to experience gods presence in their lives are also consistent with the process of metakinesis as conceptualized by luhrmann this process involves learning to identify sen sations as signs of gods presence and using these attributions to develop relational practices the participants described learning to hear and feel god better engaging in regular spiritual activities and being guided by those around them to interpret certain experiences as gods presence the participants experiences of god and sensemaking processes were embodied active and situated in their social context the participants experiences shaped their beliefs but these experiences were themselves shaped by their beliefs and by the beliefs of those around them in an active iterative and embodied process this process is ontologically ambiguous and neither assumes nor denies the validity of individuals emic interpretations of their experiences fowler noted that people tend to love and value that which loves and values them these participants came to know god through experiences of love and mercy they responded with love and service of their own the bible and the traditions of their church helped shape the participants knowledge of god but their personal experiences of god through these things was especially influential emotional intellectual and social factors supported each other and gave the participants a robust and cohesive experience of living with their god their experiences of being in a loving relationship with god and feeling his touch in their lives assured the participants of the reality they believed in the support of other christians helped develop these beliefs and provided encouragement and guidance in times of crisis the combination of these many different elements of their lives helped them to grow closer to god and sustain their faith enhancing their subjective wellbeing and lives limitations and future directions for research this study does not claim to describe the experiences of all baptists in britain let alone all christians ipa does not attempt to produce overarching descriptions of the experiences of a broad group instead it develops understandings of how individuals experience and make sense of complex phenomena by exploring idiographic details and contextualizing them in ways that refine and illuminate our understanding of phenomena there were variations between the experien ces of different participants as well as between the experiences of individual participants at different times in their lives that might have been masked by quantitative or nomothetic approaches our analysis of the data suggests these nuances are important for understanding not only the current experiences and beliefs of the participants but also how and why they have changed during their lives ipas strong idiographic commitment is a strength that enhances the analysis rather than a weakness future research exploring religiosity spirituality and meaningmaking should consider the broad range of things that can influence individuals beliefs and experiences examining the different ways these influences and experiences are integrated by individuals this study demonstrates the importance of the interactions between many different experiences in the development of individuals worldviews and shows the role that seemingly mundane experiences can play in shaping and sustaining beliefs researchers should also be sensitive to both the diversity of experiences between individuals and the different ways that seemingly similar experiences can be made sense of by different individuals or by the same individual at different times ipas reliance on a double hermeneutic where interpretations of experiences are unavoidably filtered through both the participants and researchers means it is inherently subjective this subjectivity is not unique to qualitative research but it is important to note the broader beliefs and culture of both the participants and researchers shaped the data and its analysis the diversity of the research team and its specialist expertise helped enhance the quality of the analysis the first authors intimate understanding of the language and theological beliefs of the participants provided a strong starting point for the analysis but this was supported by careful and iterative probing of the participants meaning both during the interviews and the subsequent analysis the strong rapport that developed in the interviews shown by the highly personal experiences the participants disclosed also helped generate rich data and insights the analysis presented here is we hope both convincing and rigorous we believe that further studies of other religious groups using ipa are the logical next step from this study to establish the transferability of our findings a broad range of studies each exploring a different group and conducted across diverse cultures could generate valuable insights into how religiosity and spirituality affect peoples lives and worldviews the conclusions that can be drawn from any single study are limited but the aggregation of findings from multiple studies can increase the reliability and transferability of research conclusions this study demonstrates both the importance of religiosity and spirituality in some individuals lives and the valuable contribution that ipa can make to their study each participant described a unique relationship with their god that was a central and vivid part of their lived experience the participants relationships with god intertwined with every aspect of their lives and understanding their experiences requires a holistic perspective that does not view their faith as something that is simply added onto an otherwise secular life the participants own experiences and the supporting experiences of those around them developed comprehensive worldviews that allowed them to make sense of their lives supplementary materials for this article the following supplementary materials are available via psycharchives • appendix annotated interview schedule index of supplementary materials

religious and spiritual experiences often form significant elements of peoples narratives about their faith and lives but the impact of these experiences is often neglected in academic studies this study investigated the connections between perceived experiences of god and beliefs in the lives of five members of a baptist church in britain using data from semistructured interviews interpretative phenomenological analysis ipa was used to explore the data and develop 11 recurrent subthemes organized into two superordinate themes knowing god and living in the world there were idiosyncratic differences between the experiences of the participants but they all perceived god communicating with them and attributed certain events to gods influence these experiences developed real and meaningful relationships with god and the participants faith affected every aspect of their lives shaping their actions beliefs and daily lived experiences the participants diverse experiences and beliefs created mutually supporting meaning systems or worldviews that were much stronger than the individual elements that contributed to them god was an intrinsic part of the participants social reality and their lived experiences cannot be adequately understood without appreciating the influence of this central aspect of their lives these findings show the importance of taking a holistic and idiographic perspective when studying religiosity and spirituality the study also demonstrates ipa is a useful and effective tool for studying lived experiences of religiosity and spirituality and supports its broader use to investigate such phenomena

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analyses further showed that covid19related anxiety played a mediating role in the connection between covid19related social media use and disordered eating at the withinperson level these findings underscore the complex impacts of social media use during lockdowns and highlight the importance of managing social media consumption to protect mental health and wellbeing in such challenging times health information meanwhile governments and health professionals have aggressively used social media to mitigate the damage caused by health emergencies 20 for example social media has been a prominent source of information about covid19 21 additionally in recent years governments in response to the epidemic have implemented public health measures such as contact tracing quarantines and isolation among others which may lead to social distancing and consequently an increase in social media usage 22 23 24 prior research has revealed the dark aspects of social media usage during lockdown 25 in particular increasing social media use and expanding pandemic information on social media during the pandemic lockdown have contributed to mental health issues flaudias et al 26 have found that exposure to covid19related media coverage was positively correlated with disordered eating and covid19related stress during the lockdown furthermore in recent years some evidence suggests that social media has become the major source of information about the epidemic during lockdown 21 in general social media usage is becoming increasingly frequent during the lockdown and it may have negative effects on mental health covid19relatedstress and anxiety and psychological distress during the covid19 lockdown recent research has indicated that protracted quarantines limits on public life and concerns about job security may increase covid19relatedstress and anxiety which may have negative consequences on mental health 2728 such as sexual compulsive symptom 29 the pandemic may also pose a risk to those with disordered eating 3031 moreover issues relating to peoples mental health were particularly observed during the period when lockdown measures were imposed according to the latest report about 80 of people reported the presence of overeating and most of them experienced psychological distress 12 as a result lockdown is likely to increase social media use as a means of communication potentially increasing the risk of covid19related stress and anxiety and psychological distress 24293233 introduction as the coronavirus disease 2019 pandemic has had a significant inflection rate and negative impact the world health organization designated it as a public health emergency of international concern in january 2020 12 to restrict the spread of the virus countries implemented rigorous measures such as travel bans and lockdowns 34 although lockdown procedures help to prevent the spread of covid19 they may increase individuals risk of mental health issues 56 among the elevated mental health issues the risk of disordered eating during the covid19 lockdowns has been welldocumented 78 disordered eating include a variety of irregular eating patterns which are highly prevalent in nonclinical populations 910 however as shown in a recent review of the impact of the covid19 pandemic on disordered eating behaviors relevant studies were mainly conducted in western countries 8 to our knowledge there is still a paucity of research on how the covid19 lockdowns may have impacted chinese adults disordered eating behaviors in china where there are distinct eating and food cultures from western countries 11 for example chinese people often see eating as a social link because of the societal obligation to establish and maintain connections 11 in addition given that social media usage was one of the main means of communication during the covid19 lockdown there have been empirical studies from western countries revealing the links between social media usage during the covid19 lockdown and disordered eating 12 13 14 however previous studies have generally adopted retrospective investigations which may bias the findings due to participants memory recall 15 as suggested 16 diary designs may avoid potential memory bias and is similar to individuals real life finally the impact of social media use on mental health especially in the context of the covid19 epidemic is still being debated with mixed and inconclusive results 1718 therefore the current study used a daily diary method to examine how daily social media usage during a pandemicinduced lockdown may be associated with psychological distress and disordered eating in chinese adults 19 social media usage during the covid19 lockdown in response to public health emergencies social media has been used to disseminate timely locallyrelevant outbreak presented a unique and unprecedented stressor that may have had distinct influences on disordered eating 31 33 34 35 its worth noting that stress and anxiety may lead to different effect on individuals emotional problems 3637 therefore it is necessary to clarify the specific effects of covid19related stress and anxiety on disordered eating according to the stimulusorganismresponse framework environmental factors interact with personal variables to shape individual behaviors 38 therefore through organismic elementswhich include an individuals own emotional and psychological processes when faced with a stimulusthese environmental circumstances might cause particular behavioral intentions andor actual behaviors 39 previous investigations have shown that exposure to covid19related information on social media can increase negative emotions 2240 in addition social isolation media exposure and negative affect have been identified as pathways that contribute to the worsening of disordered eating 41 in applying this framework to the current pandemic habitual exposure to negative covid19 information on social media can amplify distressing perceptions of the epidemic potentially leading individuals to develop disordered eating behaviors as a means to distract themselves from psychological distress and covid19related stress and anxiety induced by the lockdown 134243 to explore these complex interactions further this study aims to bridge this gap by employing a daily diary study design allowing for the examination of the dynamic relationships between covid19related social media usage psychological distress covid19related stress and anxiety and disordered eating over the course of the lockdown period the present study to fill the above mentioned gap in the literature this study uses a weeklong diary design on a sample of chinese individuals who were in lockdown by studying these variables within the context of the lockdown period we can gain a better understanding of how social media usage in particular situations affects individuals mental health and its potential influence on disordered eating among chinese our working hypothesis is that daily covid19related social media use predicts both direct and indirect daily disordered eating via daily psychological distress stress and anxiety in addition multilevel modeling allows us to examine whether differences in covid19related social media across persons or between days within people better explain disordered eating in general we hypothesize that covid19related social media usage is positively correlated with disordered eating among chinese people during a lockdown covid19related stress and anxiety and psychological distress are positively related to covid19related social media use and disordered eating and covid19related stress and anxiety and psychological distress are significant mediators of the relationship between covid19related social media use and disordered eating methods participants and procedure we recruited participants from community websites between december 2021 and january 2022 during the xian province full lockdown by posting the recruiting message for approximately 3 days with details regarding the research protocol as we were only interested in nonclinical samples of adults who were under lockdown the following eligibility criteria were used being above the age of 18 years selfreported having no history of mental disorders and being under lockdown during the recruitment period 114 people consented to participate in our study and were invited to join our wechat group after excluding 11 people who were not under full lockdown 103 participants remained all participants read the informed consent form the wenjuanxing online survey platform was used to collect data the informed permission form which was required to access the surveys was located on the first page of the survey the initial survey collected a range of sociodemographic information every evening at 7 pm a wechat text message was sent to participants with a url to the survey by 11 pm the same evening they were directed to submit the survey through the url participants who completed a valid diary entry on at least four out of the seven research days were eligible to receive the full remuneration however four peoples data contained less than 4 days of completed surveys and were excluded finally our study included 645 data points from 96 participants the samples mean age was 2590 years and bmi based on selfreported height and weight varied from 1502 to 2930 kgm 2 of the participants 646 were women all procedures performed in this study involving human participants were in accordance with the ethical standards of zhengzhou university and with the 1964 helsinki declaration and its later amendments or comparable ethical standards measures in particular due to the special isolation environment in order to reduce the fatigue and practice effect of the subjects we used the short version of each questionnaire as far as possible daily social media usage for covid19 information to measure daily covd19 social media usage we adapted the one item for assessing social media usage 44 specifically the item was since this time yesterday how much time did you spend on covid19 information websites on social media responses had a freeform format and were provided in hours and minutes for the sake of this analysis responses were translated to minutes daily covid19related stress in line with previous study covid19related stress was measured by three items and we adapted these item 4546 these items are scored on a 7point likert scale with higher scores indicating greater degrees of covid19related stress in this study the cronbachs α value for the scale was 090 daily covid19related anxiety in line with previous studies covid19related anxiety was used a 1item to measure 3334 meanwhile daily covid19related anxiety we adapted one item from specifically participants were asked to respond to how anxious are you about the coronavirus covid19 pandemic today on a scale of 1 to 7 daily psychological distress the short kessler psychological distress scale was used to investigate participants daily psychological distress 47 participants responded to all k6 items which inquire about the frequency of symptoms experienced over the previous 30 days using a 5point likert scale from 0 to 4 higher scores indicate greater degrees of psychological distress in line with a previous study the method of measuring daily psychological distress was adjusted to inquiring about ones emotions in the preceding 24 h 48 in this study the cronbachs α value for the scale was 093 disordered eating same as in previous study to measure daily changes in eating during lockdown used two items and adapted these items 13 participants were asked i have become more preoccupied with foodeating today and i have found it more difficult to regulate or control my eating today participants assessed each item on a scale of 1 to 5 higher scores indicate greater degrees of change in eating habits in this study the cronbachs α value for the scale was 073 data analysis spss 240 was used to perform the initial evaluation of the data including means and standard deviations for each variable meanwhile correlations between variables were estimated next a twolevel nesting structure was used to test all hypotheses observations were modeled at level 1 and participants were modeled at level 2 unconditional models including no predictor variables were tested for change in eating to ensure a twolevel structure was achieved we achieved this goal through computing intraclass correlation coefficient for each variable through mplus 81 this method captures withinand betweenperson variability small icc values indicate high withinperson variability relative to betweenperson variability variance partitioning results revealed that the intraclass correlation coefficient was 045 for the covid19relatedsocial media 059 for covid19relatedanxiety 069 for covid19relatedstress 075 for psychological distress and 045 for disordered eating indicating that intraindividual fluctuations explained a significant amount of the variances in the outcome variables therefore the multilevelmodeling approach was appropriate to test our hypotheses finally we conducted multilevel path analyses in mplus 81 49 for the nested data which simultaneously estimated all path coefficients in the full model specifically for mlms containing observationlevel predictors models were specified to allow for fixed and random effects fixed effects are defined as the average effect of the independent variable on the dependent variable in an individual 50 random effects indicate whether there is evidence that a fixed effect varies randomly across different participants within a sample 50 we tested the model to assess whether there is a positive relationship between individuals social media use regarding covid19 and their daily covid19relatedanxiety and stress psychological distress and disordered eating furthermore we tested for mediation effects in the event of positive results indirect effects were tested using a bootstrap estimation approach with 5000 samples results preliminary analysis table 1 presents the means standard deviations and intercorrelations for the study variables as expected at the withinperson level individuals information browsing about daily covid19related social media usage was positively related to daily covid19relatedstress daily covid19relatedanxiety and daily psychological distress daily covid19relatedstress and daily covid19relatedanxiety were positively related to psychological distress meanwhile these three negative outcomes were positively related to individuals daily disordered eating moreover we found the same pattern of correlations between variables at the betweenperson level multilevel path analysis table 2 and fig 1 presents the results from the multilevel path analysis that estimated all the path coefficients including those at the withinperson and betweenperson levels simultaneously the results show that individuals information browsing about covid19 in social media could not directly predict their disordered eating at the withinperson level or the betweenperson level however individuals information browsing about covid19 in social media could affect their disordered eating only through covid19relatedanxiety at the betweenperson level meanwhile at the withinperson level individuals information browsing about covid19 in social media could affect their disordered eating through covid19relatedanxiety and psychological distress simultaneously in addition covid19 anxiety could not predict individuals psychological distress at the betweenperson level but both covid19 stress and covid19 anxiety could predict psychological distress at the withinperson level therefore at the withinperson level the chain mediating roles of covid19relatedanxietystress and psychological distress were another important link in the relationship between individuals information browsing about covid19 in social media and their disordered eating discussion in this daily diary study we focused on how covid19related social media usage affects individuals disordered eating through covid19relatedstress and anxiety and psychological distress overall the results of this study are consistent with the previous studies that identified lockdowns negative effect on individuals mental health 1225 specifically more covid19related social media usage during lockdown may arouse higher levels of covid19relatedstress and anxiety and psychological distress furthermore these psychological problems may lead to individuals disordered eating more importantly the present study tested the predictive relationship between these variables through a daily diary study and found that covid19relatedanxiety plays a more important role in the relationship between covid19related social media usage and disordered eating than other factors our results suggest that first covid19related social media usage during lockdown could not directly predict individuals disordered eating whether at the withinperson or betweenperson levels although some studies have shown that the two are closely related 121426 our results indicate that the direct condition of individuals disordered eating is from other factors anxiety stress and psychological distress caused by covid19related social media usage has a stronger positive association with disordered eating we speculated that the mediating role of these three may explain the main association between covid19related social media usage and disordered eating thus leading to an insignificant direct effect in our model second covid19related social media usage was found to positively predict covid19relatedstress and anxiety at both the withinperson and betweenperson levels this result is consistent with previous studies 2629 this aligns with the sor frameworks assertion of environmental factors influencing internal states 39 however our results indicate that covid19relatedanxiety could predict individuals disordered eating but covid19relatedstress could not we speculate that this may be due to the differences between the two and between how individuals respond when faced with the two compared with anxiety stress is more like a precondition of individuals emotional problems 36 although it has negative attributes it may not directly cause specific psychological problems which depends on an individuals coping style when stress is caused by external events people generally manage and deal with it in two ways positive and negative coping styles positive coping styles include problem solving seeking help and reconstruction negative coping styles include escape denial and fantasy 51 people could use positive coping strategies to reduce the impact of stress 52 however anxiety is more difficult to manage individuals usually relieve anxiety through distracting exercising meditating and sleeping but these methods are limited under a lockdown environment which may deteriorate peoples anxiety and cause disordered eating 3041 this variation in response within the organism component of the sor framework is critical in understanding individual differences in coping with pandemicrelated stressors third at the betweenperson level only covid19relatedanxiety could mediate the relationship between covid19related social media usage and disordered eating which implies that the anxiety caused by social media usage in lockdown situations can be integral to peoples change in eating given that our mediation models included multiple covariates including covid19related stress and psychological distress the nonsignificant effects suggest that covid19related anxiety was more significant between covid19related social media usage and disordered eating than covid19related stress and psychological distress this result is an important guide for the governments segregation management policy this highlights the significant role of specific organismic responses in the framework underlining the importance of considering individual psychological factors in the stimulusresponse relationship the government should verify covid19 information available on social media to ensure that the public is informed of news that is scientific true and accurate regarding the available covid19 information it is important for the government to consider which kinds of information brings the most anxiety to people if it is rumors about covid19 that cause the most anxiety then strict management of the online environment can significantly reduce individuals anxiety and thus protect their mental health furthermore more targeted advice on mental health protection for people in isolation can then be provided in this postpandemic period as governments ease or lift quarantine measures the lasting influence on individual lifestyles especially in social media usage is evident 53 for instance there has been an increase in using social media for healthrelated information 54 highlighting its evolving role in the dissemination of medical services postpandemic however the increased reliance on social media simultaneously highlights the risk of its excessive use 5556 this dual aspect of social media usage serving both as a tool for health information and as a factor that could negatively impact mental and physical health calls for a balanced approach future research should focus on the longterm effects of these behavioral changes exploring strategies for fostering healthier online habits this study has some limitations the measurements in this study are all from the selfreport of the participants other objective indicators should be included in future studies in addition we relied on only two questions to measure disordered eating because our study was done during a lockdown this narrow scope may not fully reflect the wide range of disordered eating behaviors that people may exhibit during lockdown scenarios future research should examine using a broader set of measures to comprehensively measure multiple disordered eating behaviors in people under lockdown furthermore the participants in this research were nonclinical adults and it is unknown if the suggested model can be used for clinical samples from the chinese community or children and adolescents finally even though the current research employed a daily diary its time frame could not have been long enough despite the fact that individuals are only alone for short periods of time the effects of isolation on a persons mental health can last for much longer through longitudinal study this topic can be further investigated conclusion this study provides empirical evidence that covid19related social media usage during lockdown has a negative effect on individuals eating furthermore our results indicate that only covid19related anxiety could mediate the relationship between covid19related social media usage and disordered eating this finding calls for more attention to be paid to the implications of anxiety on individuals mental health when they are in a lockdown competing interests the authors declare that they have no competing interests • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from

background despite previous studies highlighting the benefits of social media use during the covid19 pandemic particularly under lockdown limited research has identified the potential detrimental consequences of social media use during lockdown therefore the purpose of this study is to examine the effects of social media on mental health in particular situations and the mechanisms underlying these effects methods a daily diary protocol was adopted a total of 96 adults m age 2590 ± 832 years were recruited from xian shaanxi province china covid19related social media use psychological distress covid19related stress and anxiety and disordered eating were measured each day for a week multilevel path analyses for the nested data were conducteddaily covid19related social media use was positively related to daily disordered eating r 13 p 001 furthermore the multilevel path analysis showed that psychological distress and covid19related stress and anxiety mediated the relationship between covid19related social media use and disordered eating at the withinperson level however only covid19relatedanxiety mediated the relationship at the betweenperson levelour findings contribute to the understanding of social medias impact during lockdown and provide implications for social media users social media platform providers mental health professionals and governments regarding the correct and sustainable use of social media during the covid19 pandemic and in future public health emergencies

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background according to social norms theory our perceptions and beliefs about the normal behavior of others influences our own behavior 1 for example the belief that others drink alcohol smoke tobacco or use cannabis heavily is expected to influence the amount a person drinks alcohol smokes tobacco or uses cannabis 2 perceptions of how much alcohol others drink have been studied mostly among students 3 4 5 6 7 8 9 10 11 overestimating or thinking that others drink more alcohol than oneself is fairly prevalent and has been identified as a strong predictor of ones own alcohol use 11 12 13 14 this misperception seems to apply to tobacco smoking 215 but less is known about whether it applies to other substances such as cannabis 1516 misperceptions have been observed among men and women nevertheless gender is a potential predictor of misperceptions of substance use by others evidence suggests that the magnitude of norm misperception is influenced by gender and that men tend to overestimate norms to a lesser extent than women for alcohol and other substances 315 various interventions have been designed to address overestimations of use by others with varying success among college students 17 18 19 these interventions aim at correcting misperceptions by providing normative feedback on prevailing alcohol and tobacco use norms one hypothesis is that individuals with heavy use will decrease their consumption by correcting their overestimation of use by others a review by moreira et al 20 provides evidence that normative feedback interventions for students have been effective in reducing alcohol use brief interventions that include webbased interactive participation where normative feedback is provided also have had positive impacts on alcohol use and other alcoholrelated outcomes many of these interventions are aimed at helping participants narrow the difference between perceived and actual behaviors of others 120 in a recent test of the theoretical underpinnings of social norms theory johnson 21 showed that individuals whose perceptions of normative alcohol use became more accurate drank less alcohol most of the substance use perceptions research has been conducted among students and focused on alcohol use as such there is a lack of knowledge on perception of tobacco use and cannabis use by others determining how frequently overestimations occur in the general population and how perceptions of use by others are associated with substance use will yield information about perceptions as a potential factor to target in preventive interventions since both substance use and perceptions may be influenced by the behavior of close peers or family members it is important to take into account whether or not individuals have been exposed to a heavy substance use environment 22 therefore we studied the association between perceptions of tobacco cannabis and alcohol use by others with participants own tobacco cannabis and alcohol use among 20yearold swiss men in the general population we hypothesized that misperceptions of substance use by others are frequent and are associated with participants current use methods the present study was part of the cohort study on substance use risk factors young swiss men were approached for enrollment in this large cohort study when they presented at army recruitment centers in the french and german sectors of switzerland a country that has a mandatory twoday procedure to assess eligibility for military service virtually all 20yearold swiss men have to participate thus csurf participants were approached and recruited as they attended the centers at lausanne and windisch even though swiss men are approached for enrollment at the same age some can attend the recruitment centers sooner than others this explains the age range observed in studies conducted at the army recruitment centers by our group 132324 switzerland is made up of 26 cantons and halfcantons the lausanne center processes conscripts from all of the frenchspeaking cantons while the windisch center processes conscripts from eight germanspeaking cantons or halfcantons to minimize the risk of underor overreporting participants were informed that all information they provided was confidential and had no implications for army conscription procedures participants were notified that the research was not connected to the army and that military personnel could not see the responses or other data from any individual virtually all center attendees were eligible to participate in the study if they gave written informed consent the ethics committee for clinical research at the lausanne university medical school approved the project during the csurf enrollment period 12564 conscripts attended the designated army centers and were given the option of completing a brief selfadministered screening questionnaire assessing alcohol and other drug use 11819 completed it all attendees were offered participation in the cohort study within two weeks after enrolment attendees who gave consent were invited by mail or email to complete the cohort study questionnaire cohort study participants completed a paperandpencil or online questionnaire containing items about substance use by others which asked them to estimate the prevalence of peer tobacco and cannabis use and the percentage of peers who drink more alcohol than they do cohort study assessment substance use the study questionnaire contained questions on drinking frequency with answer choices of number of days per week 23 times a month monthly or less or never and on alcohol quantity with a single openended answer the time frame was the past 12 months number of standard drinks per week was obtained by multiplying the frequency and quantity questions a standard drink was defined as 100 ml of wine 250 ml of beer 275 ml of premixed drink containing spirits or 25 ml of spirits pictures of the drink equivalences accompanied each questionnaire tobacco use was assessed with the following items participants reporting any cigarette use over the past 12 months completed questions on tobacco frequency with answer choices of every day 12 34 or 56 days a week 23 days per month or once a month or less and on tobacco quantity with a single openended answer the number of cigarettes smoked per week was obtained by multiplying frequency and quantity questions cannabis use was assessed as follows participants reporting any use by cannabis over the past 12 months completed a question on frequency with answer choices of monthly or less 24 times a month 23 times a week 45 times a week or every dayalmost every day perceptions perceptions of smoking cannabis and alcohol use by others were assessed with the following items what is the percentage of men your age that are smoking cigarettes what is the percentage of men your age that are using cannabis what is the percentage of men your age who are drinking more alcohol than you do additional variables participants were asked whether or not they have family members with alcohol or drug problems family history was considered positive when at least one parent or sibling had an alcohol or drug problem participants were also asked the number of their close friends who have alcohol or drug problems and were coded positive if they replied with some or most the three choices were later collapsed into a dichotomous variable to indicate a heavy alcohol or drug use environment due to a strong association between presence of close friends with an alcohol problem and presence of close friends with a drug problem those two variables seemed to be carrying the same information thus a single variable was created education level was also reported substance use in the census prevalence of tobacco and cannabis use census data from the short screening instrument that 94 of all conscripts completed was used to determine the prevalence of tobacco and cannabis use to lessen the risk of exaggerated overestimations of prevalence of use in our study we adopted a conservative attitude towards determining overestimations therefore we chose the most inclusive definition of the prevalence of use in the census in establishing the prevalence of tobacco and cannabis use we considered those reporting any use of tobacco or cannabis over the past 12 months to be a user alcohol consumption census norms were computed with the alcohol consumption data from the 11819 individuals the drinkingfrequency and alcoholquantity questions were multiplied to obtain the number of standard drinks per week overestimation underestimation and accurate estimation of substance use by others tobacco and cannabis use overestimation underestimation and accurate estimation of the use of substances by others was determined by assessing how participants rated the prevalence of tobacco and cannabis use among peers of the same age and sex compared with the prevalence established in the census a perceived prevalence within the ± 10 range of the prevalence established in the census was considered an accurate estimation of use by others we a priori chose a ± 10 range for its clinical utility and to match the definitions found in other studies in the literature 1525 a smaller range could lead to a bias in favor of demonstrating that youth overestimate substance use by others proportions of conscripts overestimating underestimating and accurately estimating the prevalence of tobacco and cannabis use were determined alcohol use perceived prevalence of alcohol use was not deemed relevant given the actual high prevalence of alcohol use in the study population 24 therefore estimations of alcohol use were made among alcohol users only and each participant was asked to estimate how many individuals drank more alcohol than they did 13 in order to determine for each person the proportion of the census that drank more alcohol than they did weekly alcohol consumption by each of the study participants was compared with the weekly alcohol consumption reported by the census the proportion of individuals in the census drinking more alcohol than a given study participant was compared with the perceived proportion reported by that participant the prevalence of overestimation underestimation and accurate estimation of peer alcohol drinking was computed in the total sample an accurate estimation was considered a perceived proportion within the ± 10 range of the computed proportion association between perception of use by others and substance use in a first step separate overdispersed poisson regression models for tobacco cannabis and alcohol use were created to compare the substance use of those who overestimated underestimated and accurately estimated substance use by others those accurately estimating the use by others were used as the reference group the tobacco model used the perception of tobacco use by others as the independent variable the cannabis model used the perception of cannabis use by others as the independent variable and the alcohol model used the perception of alcohol use by others as the independent variable outcome measures were number of cigarettes smoked per week for the tobacco model number of days with cannabis use per month for the cannabis model and number of standard drinks per week for the alcohol model all three models were adjusted for age education level and linguistic sector in a second step presence of close friends with alcohol or drug problems and family history of alcohol or drug problems were added to the models then adjusted for age education level and linguistic sector results table 1 shows the characteristics of the 5216 participants nearly all of the conscripts reported some alcohol use in the past 12 months about half used tobacco and nearly a third used cannabis among tobacco smokers the mean number of cigarettes per week was 481 among cannabis users the mean number of days per month using cannabis was 70 for the alcohol users the mean number of drinks per week was 84 in the census past12month prevalence was 445 for any tobacco use 363 for any cannabis use and 906 for any alcohol use perception of substance use by others the prevalence of tobacco use was overestimated by 461 and accurately estimated by 373 of study participants the prevalence of cannabis use was overestimated by 218 and accurately estimated by 316 of the participants when comparing their own alcohol use with alcohol use by others more than half of participants overestimated while 310 accurately estimated the proportion of participants overestimating accurately estimating and underestimating substance use is reported in table 2 participants overestimating accurately estimating and underestimating tobacco use by others reported a mean of 254 209 and 202 cigarettes smoked per week respectively participants overestimating accurately estimating and underestimating cannabis use by others reported a mean of 38 23 and 13 days of cannabis use per month respectively participants overestimating accurately estimating and underestimating alcohol use by others reported a mean of 111 70 and 29 drinks per week respectively associations between perception of use by others and substance use separate overdispersed poisson regression models for tobacco cannabis and alcohol use were used to assess the associations between perception of use by others and substance use all models were adjusted for age education level and linguistic sector results are expressed as incidence rate ratios for the count variable in the model standard drink 100 ml of wine 250 ml of beer 275 ml of premixed drink containing spirits or 25 ml of spirits when participants reported that some or most of their close friends had an alcohol or drug problem the variable was coded positively we considered that a family history of alcohol or drug problems was present when participants reported at least one parent or sibling with an alcohol or drug problem the three count variables under study were number cigarette smoked per week number of day of cannabis use per month and number of standard alcohol drinks per week the irr gives the factor change in the expected count compared with the reference category for example if participants with characteristic x are compared with the reference group without the characteristic x with respect to their weekly alcohol use an irr 1 means that holding all other variables constant having the characteristic x does not change the expected number of drinks per week an irr 08 means that on average the group with the characteristic x reports 20 less drinks per week than the group without the characteristic x and an irr 2 means that on average the group with the characteristic x reports twice the number of drinks per week than the group without the characteristic x tobacco use compared discussion perceptions of substance use by others are associated with ones own use among young men specifically our results show that overestimating substance use by others is associated with greater consumption in addition underestimating the substance use by others appears associated with less use except for tobacco our study adds important information about the frequency of overestimation underestimation and accurate estimation of substance use and the association of overestimation of use by others with current use especially for tobacco and cannabis use where evidence has been scarce 21626 the magnitude of the associations between perceptions and usage was similar in the models where variables such as having close friends with alcohol or drug problems or having a family history of alcohol or drug problems are added or taken out the relationship most affected by the addition of these variables in multivariable models was overestimation of cannabis use by others and participants own cannabis use these results are in line with the literature 11131416 the magnitude of the observed associations between perceptions of use by others and substance use are of clinical significance compared with participants accurately estimating alcohol use by others participants who overestimated alcohol use by others reported drinking almost 60 more per week those underestimating alcohol use by others reported drinking 60 less per week than those accurately estimating for cannabis these differences were also of clinical significance and were in the 40 range though smaller the association between perception of tobacco use by others and tobacco use was still clinically significant participants overestimating tobacco use by others smoked 17 more cigarettes per week compared with those accurately estimating it as a potential target of normative feedback interventions overestimations of use by others have been the focus of various research studies our results show that overestimations of substance use by others are frequent among young men and are associated with greater consumption these associations are independent of being in a heavy alcohol or drug using environment indicating that even in the case of proximity to these groups overestimations of use by others may influence ones own use our results show that the overestimation of use by others has a stronger association with ones own use for cannabis and alcohol than it does for tobacco this suggests a potentially differential influence of perceptions on ones own use of these substances an alternate explanation for overestimations is that individuals select their friends and acquaintances based on shared preferences in alcohol tobacco and drug use and overestimations of behaviors within a distal group of the same of peers of same age and sex may reflect peer usage more than anything else may using distal groups in research on substance use perceptions has faced criticism and has been presented as a source of exaggerated overestimations 27 we attempted to take into account the influence of a heavy using environment and heritability by showing independent associations of ones own use and overestimations of others use with presence of close friends and family members with alcohol and drug problems even though misperceptions of a distal group are less likely to have an influence on behavior than misperceptions of a proximal group we still observed associations between overestimations and substance use 28 we observed strong variations in the frequency of overestimation by substance overestimation of alcohol and tobacco use was observed in more than 45 of the participants while overestimation of cannabis use was observed in 22 of participants we do not have a straightforward explanation for the lower rates of overestimation of cannabis use one possible explanation is that cannabis may have received less attention than tobacco and alcohol or its consumption may be less visible due to its illegal status in switzerland determining the causes of these variations is an area for future research the association of secondary variables with participants own substance use is concordant with research showing that environmental 29 30 31 and genetic influences 32 play a role in individuals substance use 22 in the present study both family history of drug or alcohol problems and markers of peer behavior were associated with substance use family history can be seen both as a marker of genetic and environmental influences since heritability and parental and familymember modeling of substance use behaviors can be associated with substance use 223233 generally family history associations were found across substances family history of drug problems was associated with alcohol tobacco and cannabis use and family history of alcohol problems was associated with alcohol and tobacco use the presence of close friends with alcohol or drug problems was also associated with substance use this study has several limitations first it should be noted that we relied on selfreported measures for substance use and other factors notably participants were asked to report whether or not they had family members or friends with alcohol and or drug problems and the psychometric properties of these questions were not tested second we assessed only descriptive norms and interpersonal perception was limited to those of the same age and sex as the participant perception of the amount of alcohol used by others in more proximal groups was not evaluated the large number of participants in the study and the logistics of the screening survey preclude gathering detailed data that could be obtained during facetoface structured interviews in addition we a priori chose a ± 10 range to define accurate perception a smaller range could have introduced a bias towards demonstrating that youth overestimate substance use by others however it should be noted that this definition impacts the prevalence of over under and accurate estimations sensitivity analyses around this criterion were performed we did not observe major differences in the associations reported herein third because it is a crosssectional design we were not able to investigate possible causal pathways or assess the influence of changes in perception on substance use in addition only 20yearold men were included and our results cannot be generalized beyond this population subset evidence suggests that the magnitude of norm misperception is influenced by gender even though misperceptions have been observed across gender their magnitude is likely to differ therefore our results should not be extrapolated to women fourth about 6 of the invited conscripts refused to complete the screening questionnaire therefore we cannot be certain that alcohol tobacco and cannabis use was accurately measured in the census nevertheless it is unlikely that this unduly affected measures of substance use prevalence in the census or significantly influenced the obtained perceptions since we were able to rely on screening data from 94 of the census cohort participation and response to cohort questionnaires may be subject to selfselection bias although minimally participants who did complete the cohort questionnaire differed from the source population substance use was lower among those who completed the cohort questionnaire compared with census data the nonresponse bias was 10 for alcohol and cannabis and 15 for tobacco use detailed analyses are presented elsewhere 3435 in 2012 hilde pape pointed out methodological limitations in studies focusing on estimations of peer substance use and argued that these restrictions may lead to exaggerated results 27 she reported that the representativeness of studies in the field is problematic because of convenience samples and low response rates in this regard our study has the advantage of using a large sample with perception items imbedded within a larger cohort questionnaire also because 94 of the source population was assessed on substance use the representativeness of our cohorts has been well characterized even if differences existed between cohort participants and the source population these differences were limited 34 other methodological concerns reported by pape include the complexity of questions used to assess perceptions particularly for the item on alcohol use perception this limitation exists in the present study asking participants to compare their alcohol use to alcohol use by others by having them determine the proportion of individuals their age and sex who drink more alcohol than they do can be challenging and assumes preexisting beliefs about the use of others questions on tobacco and cannabis use perceptions were less complex even though they also assumed preexisting beliefs and did not include i dont know as a choice there is no way to determine the level or strength of preexisting beliefs in an individual therefore the present study is also limited by the complexity of the questions used to assess perceptions nevertheless we believe our study has some notable strengths we were able to assess actual and perceived substance use in samples from the same population that included consumption screening data from 94 of the census and from a large sample of cohorts we took into account proxies of peer use in the adjusted analyses which allowed an assessment of independent associations between perceptions of use and ones own use even though interpersonal perceptions were limited to peers of the same age and sex the fact that we assessed family history and the presence of close friends with substance use problems strongly supports the hypothesis of an independent association of perceived substance use by others with ones current own use also we used norms that are usually used in available normative feedback interventions conclusion our results confirm among young men in the general population what has already been seen in selected student populations ie overestimations of substance use occur frequently and are associated with greater usage although we cannot make a causal interpretation because of our study design our results suggest that perceptions themselves may influence current behavior and that those who overestimate substance use by others are indeed likely to use more themselves we believe our study adds information on the prevalence of misperceptions for substances other than alcohol it is important to note that 3040 of the participants accurately estimated use by others and that a substantial proportion underestimated use by others if preventive interventions are to be based on normative feedback and their aim is to reduce misperceptions then the prevalence of overestimation indicates that they may benefit about half of the population or in the case of cannabis as little as about 20 of the population to be successful such interventions should take into account differential strengths of association across substances especially if largescale efforts to implement interventions based primarily on this theoretical rationale are attempted competing interests the authors declare that they have no competing interests

background interventions have been developed to reduce overestimations of substance use among others especially for alcohol and among students nevertheless there is a lack of knowledge on misperceptions of use for substances other than alcohol we studied the prevalence of misperceptions of use for tobacco cannabis and alcohol and whether the perception of tobacco cannabis and alcohol use by others is associated with ones own use methods participants n 5216 in a cohort study from a census of 20yearold men n 11819 estimated the prevalence of tobacco and cannabis use among peers of the same age and sex and the percentage of their peers drinking more alcohol than they did using the census data we determined whether participants overestimated accurately estimated or underestimated substance use by others regression models were used to compare substance use by those who overestimated or underestimated peer substance with those who accurately estimated peer use other variables included in the analyses were the presence of close friends with alcohol or other drug problems and family history of substance use results tobacco use by others was overestimated by 461 and accurately estimated by 373 of participants cannabis use by others was overestimated by 218 and accurately estimated by 316 of participants alcohol use by others was overestimated by more than half 534 of participants and accurately estimated by 310 in multivariable models compared with participants who accurately estimated tobacco use by others those who overestimated it reported smoking more cigarettes per week incidence rate ratio irr 95 ci 117 range 105 132 there was no difference in the number of cigarettes smoked per week between those underestimating and those accurately estimating tobacco use by others irr 95 ci 099 range 084 117 compared with participants accurately estimating cannabis use by others those who overestimated it reported more days of cannabis use per month irr 95 ci 143 range 121 170 whereas those who underestimated it reported fewer days of cannabis use per month irr 95 ci 062 range 023 075 compared with participants accurately estimating alcohol use by others those who overestimated it reported consuming more drinks per week irr 95 ci 157 range 143 172 whereas those who underestimated it reported consuming fewer drinks per week irr 95 ci 041 range 034 050 conclusions perceptions of substance use by others are associated with ones own use in particular overestimating use by others is frequent among young men and is associated with ones own greater consumption this association is independent of the substance use environment indicating that even in the case of proximity to a heavyusage group perception of use by others may influence ones own use if preventive interventions are to be based on normative feedback and their aim is to reduce overestimations of use by others then the prevalence of overestimation indicates that they may be of benefit to roughly half the population or in the case of cannabis to as few as 20 such interventions should take into account differing strengths of association across substances

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background youth and young adults individuals between the ages of 15 and 24 1 represent the greatest risk group by age for adverse sexual health outcomes such as sexually transmitted and bloodborne infections unintended pregnancy sexual harassmentassault including misogyny and homophobia 23 transmission of stbbi and unintended pregnancies 2 3 4 in youth and young adults may be caused by inconsistent condom use 56 highrisk behaviours such as drug and alcohol use social mediarelated sexual encounters and multiple partners 7 8 9 10 stbbi can contribute to many serious health complications such as reproductive cancers and infertility and the presence of one or more symptomatic stbbi significantly increases the risk of hiv transmission 11 12 13 young adults are one of the most mobile generations in terms of international experiences 14 in 2015 23 of all international travellers were young adults 15 young adult travellers are more likely to spend long periods abroad with purposeful travel work study volunteer or language opportunities steadily replacing leisure travel 15 motivations for international travel include interactions with local citizens and a desire for an immersive local cultural experience 15 due to the covid19 pandemic international travel is reduced significantly including crossborder travel between canada and the united states 16 vaccinations are gradually increasing canadian international travel in 2021 17 with normal travel volume anticipated postpandemic the popularity of international travel has created a healthcare sector focused on the provision of travelrelated health information 1819 the field of travel medicine is predominantly preventative ensuring predeparture review counselling and management of destinationspecific risks itineraryspecific risks and risks specific to the individual travellersuch as preexisting conditions 20 pretravel health consultations typically include individual risk assessment medical history health risk education and related mitigation strategies specific to the travel region as well as relevant immunizations and medications for prophylaxis and selftreatment 2122 stbbi are among the communicable disease risks faced by travellers based on their destination or their planned activities 20 it is difficult to quantify the impacts of travel on adverse sexual health outcomes due to the heterogeneity of travellers trip characteristics and destination regions 23 24 25 26 27 a systematic review estimated the prevalence of travelassociated casual sex as 204 with approximately 494 unprotected sexual encounters 27 risk factors for travelacquired stbbi include casual sex single status alcohol or drug use lack of travel advice male higher number of sexual partners and inconsistent condom use 2327 although discussion of sexual risk behaviours in pretravel consultations by health practitioners is a best practice 20212829 the quality and frequency of sexual health promotion is less well known ottawa ontario is the bilingual capital city of canada home to 934243 residents including 125840 young adults aged 1524 years 30 prepandemic canadians were avid travellers with 287 million international trips in 2010 446 representing travel by ontario residents 31 although the united states remains the most popular destination canadian travellers also include overseas backpackers volunteers traveling to lowincome countries and immigrants returning in their country of origin to visit relatives 32 canadian generation z travellers prioritize experiential travel that includes physical activity exploration and inspiration 33 given the increased risk of adverse sexual health outcomes including stbbi unintended pregnancy and sexual harassmentassault among travelling young adults travel health interventions can be considered an essential component of public health this study aims to investigate the experiences practices and recommendations of ottawaregion professionals employed in fields of travel medicine sexual health or traveltour agencies within the context of young adult travellers sexual health methods sample recognizing that young adult travel may include predeparture consultations with both travel organizers and travel health providers eg recruited travel health sector key informants to participate in semistructured interviews through purposive sampling by email phone or in person to best capture an overview of the travel health sector interviews with key informants convey by proxy the experiences practices and culture within their respective organizations 3435 inclusion criteria for key informants were as follows professionals employed in the travel sector within the ottawa region who routinely provided pretravel health counselling and guidance to young adults and were able to participate in the interview in english or french lack of englishfrench language proficiency organizations which did not offer services in the ottawaregion and professions limited to travelitinerary arrangements were exclusion criteria thirteen key informants from 11 different organizations including travelhealth clinics sexual health clinics youngadultfocused tour agencies and healthpromotion groups with no restriction on the type of organizationbusiness were recruited given that key informants were drawn solely from organizations based in the ottawaregion and that there are limited such travel services which provide guidance and counselling related to health and wellness this sample size was deemed adequate 36 to reflect a diverse breadth of local organizations and upon data analysis saturation was achieved 37 data collection the interview guide was informed by the world health organizations sexual health conceptual framework 38 which promotes sexual health as the holistic achievement of physical emotional mental and social wellbeing framed by human rights evidencebased and a sexpositive approach interview topics included key informants roles in travel interventions related to sexual health perceptions of young adult ottawaregion travellers sexual health and experiences practices and recommendations for travelrelated sexual health promotion challenges and barriers to sexual health promotion and demographics data analysis interviews were audiorecorded transcribed and analyzed in the original source language with field notes confirming that thematic saturation was reached 3940 translations of sample quotations from frenchspeaking participants appear in this article interview transcript data coded using nvivo were analyzed using both inductive 3940 and deductive approaches supported by the who sexual health framework 38 and the interview guide eg analyzed the data iteratively and the research team reviewed and discussed the interpretation and qualitative content analysis 39 to fully develop our understanding of the data ethics all methods were performed in accordance with relevant medical ethics and research guidelines and regulations all study protocols were reviewed and approved by research ethics board at the university of ottawa eg conducted english and french interviews in person or via skype between aprilnovember 2017 with seven englishand six frenchspeaking participants each of whom provided written informed consent to participate in the study results participant characteristics key informants included seven professionals working in a healthrelated organization and six employed by travel services the majority of the key informants identified as female and had less than 10 years of experience in their current field of work recognizing that mandates of healthcare are distinct from travel services our presentation of the findings notes major differences between these groups pretravel interventions in general key informants described pretravel interventions tailored to the mission of the tour agency or the destination region with sexual health not considered a core component themes related to informants pretravel practices emerged as either riskassessment approach andor practical or purposedriven interventions healthcare key informants typically used riskassessment approaches to mitigate disease risk or potential health hazards associated with the destination region typical pretravel healthcare interventions included vaccinations medications and general travel advice when asked how young travellers sexual health could be improved a female travel nurse said … we have to focus on vaccines and medications like malariawe have to focus on the risks of illness following the guidelines and directives of the host organization a travel services informant recognized the riskassessment approach used by healthcare workers and recalled that the nurses responsible for the pretravel health module training emphasized risks related to diseases travel services participants reported that most humanitarian or volunteer opportunities are organized as group activities although practices varied across different host organizations informants used practical or purposedriven interventions tailored to the collective needs of the group travel services key informants noted little emphasis on sexual health in the pretravel health discussions we have only one slide on sexual health what is said is things like dont forget your condoms or if you are a woman and are on the pill talk with your family physician and ask them for a prescription and make sure you have enough we tell them condoms are not always available in all sizes in all different countries so bring what you need theyll find that funny but at least we tell them translation female program director travel services eg02 participants from travel services perceived that healthcare professionals were better able to address sexual health topics with pretravel health interventions outsourced to travel nursesmedical clinics its not our responsibility to do their sexual education necessarily but we remind them that sex isnt the same abroad not everything we have here is available abroad that if they need prescriptions they need to think about that to put it on their todo list i think its part of our responsibility but im not sure that i have the right competence to go in depth we dont focus on health translation female program director travel services eg02 although sexual health was most often discussed in terms of casual sex participants were cognizant that adverse sexual health outcomes could include harassment and assault the riskassessment approach was used to discuss travelsafety which both health and travel services key informants discussed in terms of acceptability of sexual expression and risks of sexual assault …we know how difficult it is for people to talk about um sex in general sexual assault and harassment in particular is even more taboo and difficult so if we talk to them before them sic leave and we tell them that there is a policy and there are procedures and we take this extremely seriously then when it does occur umand the percentage of it occurring are quite high … theyll be more likely one to report it if um theyre the victims of harassment or assault and two to be more aware of it happening in their environment female program director travel services eg07 our patientsits really to talk about safe sex uh we will discuss if theyre travelling to a country where theres a high incidence of hiv … i talk about for young girls especially travelling to certain places where it might be dangerous for them that there has been cases of rape even kidnapping in things like group rapefemale nurse eg03 in fact we talk about sexual harassment a lot from a work perspective we also talk about homosexual relations which for us too is a major issue because in many countries where we operate homosexuality it is either prohibited or criminal or otherwise it is taboo some countries even its illegal translation male program officer travel services eg11 key informants from volunteertravel services mentioned that nosex contracts or nosex policies for travellers were quite common although such abstinencepolicies were rarely enforced in the field somebody told me that like years ago there used to be a message like uptake barriers related to the accessibility of sexual health promotion itself by young travellers barriers to sexual health uptake by travellers were categorized as three subthemes young adults embarrassment travelhealthcare professionals discomfort and travellers financial constraints both travel services and healthcare respondents described young travellers discomfort with sexual health discussions perceived shyness apparent disinterest or requests to change topic when sexual health was introduced i think theyre also very shy people are just generally shy and not comfortable speaking about sexual health female travel nurse eg01 some it seems like theyre just coming in for that vaccine its to get their attention to talk about everything else but youll see their eyes glaze over and you know theyre already thinking or theyre on their phone texting somebody and they think that the visits over female travel nurse eg03 we have to just judge from their response whether theyre open to it or not right you know some say i know i know you dont have to tell me like thatthen obviously im not gonna go into it too much male travel physician eg08 key informants considered that although some young adults overestimate their personal knowledge about sexual health others are uncomfortable talking about sex especially if there are no plans to have sexual relationships while abroad a travel services participant perceived that young adults feel condescended to when the topic of sexual health is discussed often they are paternalized often its a bit like you impose a decision on them…sometimes youths think they know a lot we have the feeling that they have an i do not care attitude they youth are like who are you to tell me that kind of things translation male program officer eg11 respondents also acknowledged that travelhealthcare professionals often feel uncomfortable discussing sexual health thereby contributing to the uptake barrier i dont think there are a lot of family doctors or travel clinics who are comfortable talking about this sexual health translation female sexual health nurse eg04 a travel nurse mentioned that her employer refused to talk about sexual health topics and referred his patients to her for sexual healthrelated questions thats why the physician didnt speak to you eg he doesnt feel as comfortable now hes an older gentleman its a different generation he doesnt like to bring up the sexual aspect of the visit so i think its a matter of even healthcare professionals feeling comfortable enough to discuss it without feeling embarrassed or shy or feeling like youre imposing your opinion but you have to put yourself outside of it somehow and be comfortable to just give factual information in a way that theyre gonna take it in female travel nurse eg03 a humanitarian travel organization key informant seemed ill at ease when discussing sexual health topics during the interview i dont think its sexual health a common topic i dont know if its because the organization might think that talking about it might encourage people… encourage sexual actions…for us its difficult… we are all together during fifteen days in the same environment…i dont think its appropriate translation female travel services mission lead eg13 respondents also considered young travellers financial limitations as barriers to their uptake of sexual health information given the consultation fees required for some travelhealth services many times young adultsbecause of cost issues and financesmaysometimes will come in and onlythey know they only want hepatitis a and b thats it sometimes they dont want to hear about anything else sometimes they only want uh whats required and the only thing that is required can be yellow fever vaccine theres nothing else thats required to go uh into certain countries so there are times where they dont want to listen to a consult they dont want all the information but mostly its because of budget they have a small budget and they want the bare necessities… our hands are tied there our cost is what it is um we cannot give free vaccines we cannot lower the prices of our vaccines … female travel nurse eg01 the cost as in the services we give have a cost behind it its not covered by ohip ontario health insurance plan if its travel if theyre coming in for their booster their visit its covered by ohip but otherwise theyre paying for their services herefemale travel nurse eg03 you never have enough time to get young peoplecertain young people comfortable enough to start talking and to get really engaged with them and when you just start to get really close to them really talking outward and honest with you and displaying their needs and their issues and getting questions their time is up and you dont get enough time with them and our services cost so its not like they can just keep coming back and back and back and taking all that time they cant afford that female travel nurse eg09 sexual behaviours and travel an overarching theme which emerged across interview questions was the recognition by both health and travel key informants that travel itself may cause young adults to engage in risky sexual behaviours key informants perceptions of the impact of travel on sexual behaviours were summarized as the following subthemes disinhibiting effects of alcohol anonymity of travel and exoticism of travel travelrelated increased alcohol intake was widely acknowledged as interlinked with casual sex well i think we all know that alcohol and sex go to together when youre away um you will drinkmost people will drink more… where theres a lot of drinking involved theyll absolutely be at a higher risk of sexually transmitted diseases and probably more frequent unplanned sex female travel nurse eg01 you know students when they travel abroad they party often they party a lot and they meet people and they are more vulnerable translation female program directortravel services eg02 the anonymity of travel being away from social networks at home was recognized as a contributing factor to increased sexual activity abroad a volunteering program officer explains youll keep your anonymity and you will do more things…and this is the danger that we often witness you have less pressure or at least the pressure you feel is different while travelling youll do things that you wouldnt necessarily do theres the exotic side of things people always have risky behaviours but while abroad ill say that 1015 even 1020 of travellers have problematic risky behaviours you allow yourself to do more things because youre just passing through the country youre more nonchalant translation male program officer travel services eg11 travellers take more risks there is a lot of infidelity people travel to have sexual encounters and be unfaithful because its less likely that youll have to deal with the repercussions if they are at home in ottawa and want to have a onenight stand casual sex there are more risks involved that people may see you or that you see your one night partner again i think that people find it easier to go on a trip and be anonymous we see a lot of that translation female sexual health nurse eg04 anonymity is undoubtedly part of the exoticism of travel but also perceptions that restrictions obligations and rules are left behind while on vacation key informants acknowledged that pretravel sexual health promotion was necessary to challenge the what happens in vegas stays in vegas culture frequently embraced by young adults … people will behave differently on vacation and maybe throw caution to the wind more female travel nurse eg03 id say that the sexual health of young adults travelling is more at risk as people are in a new context one of adventures new experiences and discoveries and because of this thrill they feel will be less cautious especially when they just arrived translation female volunteering organization recruitment agent eg12 … you know the famous notion of when you are abroad anything goes then i think you start to associate it with a lot more abroad than at home… translation male program officer travel services eg11 a healthcare professional considered that many young adults may return from travel and reflect on their travelrelated sexual behaviours with regret health or safety concerns resulting in posttravel anxiety people will travel come back and only then will the reality strikes theyll be very very anxious and theyll have regrets about behaviours they had or things that happened there will be a lot of anxiety like what have i done anxiety towards stis towards sti testing things like that we often see anxious people coming back from a trip who have regrets and fears concerning their sexual health translation female sexual health nurse eg04 key informant recommendations when asked to provide recommendations related to sexual health and travel several themes emerged about key informants general perceptions of young adults early sexual health promotion and education is a determinant of adult sexual health and wellbeing young adults exhibit a general lack of sexual health knowledge and comprehensive sexual education targeted to youth and young adults is the recommended strategy to improve these knowledge gaps we can obviously do more because we have such a high rate of sexually transmitted diseases so obviously were not doing our job for sure there could be more done and more taught starting from maybe making it easier taught in schools but they do talk about it … i do believe that there is a lot of ignorance and a lot of young people they still think that they are invincible it only happens once or its not going to happen to me female travel nurse eg01 i think theres this idea still that maybe a lot of us young adults are invincible and that it happens to other people and i think theres a lot of myths and misinformation when it comes to health definitely female sexual health counsellorcoordinator eg06 discussion we report here that sexual health is generally omitted discussed superficially or considered an awkward uncomfortable topic by ottawaregion key informants respondents recognized that the anonymity and exoticism of travel along with use of disinhibiting substances like alcohol and drugs increased travelassociated sexual behaviours among young adults healthcare key informants prioritized riskassessment driven interventions emphasized infectious diseases other than stbbi prophylactic vaccinations and general health and safety whereas travel services participants relied on practical or purposedriven interventions tailored to the immediate needs and activities of the travellers key informants identified barriers to the dissemination of sexual health promotion but also perceived that uptake of such messaging was impeded by provideryoung adult discomfort and embarrassment with the subject a 2016 systematic review identified that less than half of travellers from high income countries received pretravel sexual health interventions 23 previous studies report that sexual health risks are rarely discussed in pretravel consultation in travel clinics 4142 consistent with our findings although pretravel sexual health promotion is a recommended best practice for travel medicine 20 evaluation of the benefits of these interventions is complicated by inconsistent nonstandard programmes heterogeneity of both providers and travellers and trip destinations 2732 whereas some studies conclude that pretravel sexual health promotion can be effective in reducing adverse outcomes 2342 other studies consider that such pretravel sexual health interventions may successfully increase sexual health knowledge and risk perception without necessarily reducing risk behaviours 4344 reported barriers to sexual health promotion reported uptake barriers of sexual health promotion during pretravel consultations include format and perceived relevance of the sexual health travelrelated promotion 2425 in our study travel and health professionals articulated discomfort lack of training and confidence associated with sexuality discussions as barriers this is consistent with implementation barriers for sexual education by teachers 4546 and clinical sexual histories counselling by medical students 4748 and nurses 4950 training and continuing education are strategies to enable sexual educators including health professionals become more assertive and confident with sexuality discussions 4649 attitudes related to perceived discomfort and embarrassment of clients students patients and in our study young travellers often reflect gaps in understanding of the importance of sexual promotion to the target audience insufficient training or other barriers including lack of time or privacy 4649 training by itself however cannot abrogate policies protocols or organization cultures which do not support open inclusive sexual health promotion 45 best practices for sexual health promotion should ensure a judgmentfree dialogue that is sexpositive 384651 tailored and relevant to the audience and is evidencebased 13852 although sexual health promotion may provide comprehensive discussion about risk reduction and safe sex broader issues related to sexualities sexual rights and gender equity are often omitted 53 inflexible personal beliefs about sexualities may bias sexual health promotion contribute to missed opportunities for needed referrals information and counsel and lead to incorrect sexual health risk assessments 47 therefore an essential starting point for inclusive sexpositive sexual health promotion is relevant training and personal reflection for providers so that they are able to meaningfully discuss these issues with trust respect and dignity a cisheteronormative lens of sexuality does not meaningfully reflect diverse sexual identities in canada 46 such that the needs of minority groups may go unaddressed with respect to sexual health and travel travel key informants discussed sexual harassment risk of sexual assault and culturallegal acceptability of homosexuality and nonbinary sexual identity expression abroad however these topics received less emphasis compared with standard pretravel consultation topics key informants framed genderbased violence along with legality of sexual expression abroad as humanresource or safety topics rather than part of the broader dialogue about sexual health responsibility for sexual violence always rests with the perpetrator however risk behaviours such as travel destination excessive intoxication accommodation nightlife activities and solo travel are associated with assaults on young women and gay and bisexual men 5455 tourismsector workers face considerable sexual harassment such that young adult travellers may also represent potential perpetrators 56 it was unclear the intent of established abstinence policies and nosex contracts for travellers described by ottawatravel services informants these policies may serve to reduce risk of sexual assault and possible legal repercussions of casual sex abroad and may also be intended to safeguard the reputation of participating travel organizations by minimizing problematic sexual behaviours of travellers abroad key informants acknowledged that these abstinence contracts were difficult to monitor and enforce stbbi healthcare key informants identified that the topic of vaccines especially hepatitis b vaccine was used as a mechanism to briefly introduce sexual health mainly hiv and stbbi in pretravel interventions emphasis on travel stbbi risk reduction is essential as globalization and travel have facilitated stbbi dispersion and impacted surveillance and treatment 23273244 indeed travellers who engage in sexual relationships abroad are exposed to new and different sexual networks 21 especially when travelling to stbbi hotspots 57 travelrelated sexual networks can facilitate the introduction of new drugresistant stbbi in the home country including drugresistant strains of n gonorrhoea 212744 as well as other bloodborne pathogens 2732 like the zika virus 5859 as young travellers particularly men are at higher risk to engage in casual sexual relationship abroad 212627 it is important that pretravel consultations address the issue of stbbi and safe sex abroad 2160 recommendations our findings indicate that ottawaregion travel and health key informants provide only limited sexual health pretravel interventions most international health organizations identify sexual health is as an essential pretravel intervention 29 committee to advise on tropical medicine and travel catmat 28 further travellers should be encouraged to follow up with posttravel interventions including sexual health assessments it is evident that ottawaregion travel services prioritize pretravel preparations rather than posttravel followup or referrals health key informants were more likely to manage posttravel incidents however there did not appear to be a systematic scheduling of posttravel followup appointments posttravel interventions to improve followup could include automated reminders issued from travel organizers airlines or public health agencies more research is needed to identify the best practices in terms of pretravel health interventions and sexual health information uptake by young travellers 61 young adults perceive health hazards such as unprotected sex as less risky compared with older adults 62 dialogues about sensitive topics such as sexual health with adolescents and young adults may create discomfort for both provider and patient 63 consistent with the views expressed by our key informants for providers sexual health training youth young adulttargeted sexual health guidelines and sexual risk assessment decision aids such as the touchscreenadministered measure sexual risk behavior inventory for primary care patients 64 may help instill confidence and ability engagement of adolescentsyoung adults in such discussions requires establishment of trust and emotional comfort initiated by informal conversation 63 our health key informants seemed to realize this however they described very little time to establish patient rapport with consultation time restricted to priority travel vaccinations once trust and rapport are established providerguided interventions that are sexpositive individuallytailored could include condom negotiation safer alternative nonpenetrative sexual practices such as mutual masturbation 4365 digital mechanisms to deliver sexual health information and recommendations should be used to complement classic providerinterventions use of digital apps such as ggd op reis 66 mytravelhealth 67 or cdcs app travwell 68 and travel smstext messages with sexual health promotion 69 may better serve this young adult demographic although we recommend modernization and diversification of pretravel sexual health promotion platforms these mechanisms should complement facetoface provider consultations which can best provide individualized counsel and provision of evidencebased advice prophylaxismitigation immunizations and medications 70 limitations this qualitative study is not meant to be generalizable or representative of the experiences and practices of all key informants working in travel clinics sexual health clinics and travel organizations several organizations declined our invitation to participate in the study citing lack of coverage of sexual health topics or discomfort with the topic this suggests a sampling bias as the key informants who agreed to participate did address sexual health to some extent or were comfortable discussing this topic conclusion the findings from our study highlight that ottawaregion health or travel key informants omit or neglect sexual health in pretravel interventions we recommend that youthfocused travel organizations emphasize within pretravel consultations for comprehensive sexual health discussions that recognize the intersectionality of sexual identities raceethnicity gender age and citizenship both travel and health key informants should consider established and emerging sexual risk assessment decision aids to facilitate sensitive discussions and use of digital technologies for efficient costeffective sexual health promotion at the population level abbreviations cdc centers for disease control and prevention hiv human immunodeficiency virus srbi sexual risk behavior inventory stbbi sexually transmitted and blood borne infections sti sexually transmitted infections who world health organization competing interests not applicable gareau and phillips bmc health services research 22145 • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from

background international travel has become increasingly popular among young adults young adults often engage in casual sexual relationships abroad exhibit sexual risk behaviours and may thus be at risk of contracting sexually transmitted and bloodborne infections pretravel interventions and consultations may mitigate this risk at present we know little about sexual healthrelated pretravel interventions the aim of this study was therefore to document key informants experiences perceptions and recommendations in the context of sexual health of young adult travellers methods key informants were professionals working in ottawa canada travel clinics travel organizations or sexual health clinics with a young adult clientele this study used a qualitative approach and consisted of 13 inperson or skype semistructured interviews with key informants thematic content analysis was informed by a sexual health framework with themes emerging both inductively and deductively results sexual health was not common in pretravel interventions described by key informants riskassessment and practical or purposedriven pretravel interventions were identified resulting in risk mitigation strategies tailored to the destination region andor missionculture of the travel organization dissemination eg limited time lack of training and uptake eg young adults embarrassment provider discomfort financial constraints barriers limited indepth discussions of pretravel interventions related to sexual health key informants acknowledged the importance of early sexual health education and recommended ongoing comprehensive sexual education for both youth and young adultsthe findings of this study suggest that more time and resources should be allocated to the topic of sexual health during pretravel interventions with young adults professionals who guide and prepare young adults for travel must develop concomitant skills in sexual health promotion early comprehensive sexual education is recommended to improve overall sexual health in young adults and mitigate risk behaviours during travel

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background globally contraceptives remain an important public health intervention for preventing unintended pregnancies and related maternal mortality and morbidity 1 2 3 4 despite these benefits studies show low use of contraceptives across subsaharan africa including ghana where the modern contraceptive prevalence rate is about 25 5 a figure slightly lower than the regional average modern contraceptive prevalence in ssa among married women or women in a union was estimated at 239 in 2012 and 285 in 2017 6 a variety of contextual factors such as servicerelated conditions accessibility availability and individual factors such as age marital status education partners disapproval challenges the availability and use of contraceptives 7 8 9 even though there is almost universal awareness and actual availability of modern contraceptive methods many women in the union do not use contraceptives due to their partners objection and other personal reasons 1011 studies show that the low rate of contraceptive use in subsaharan africa may be the result of partner disapproval of contraceptive use 12 13 14 limited choice of male contraceptives perceived harmful side effects of female contraceptives and suspicions of spousal infidelity have also been identified as reasons for mens objection to family planning methods 15 16 17 18 19 the limited emphasis on men perhaps explains the scarcity of knowledge regarding the influence of men in the contraceptive decisions of their partners this study is informed by gender and power concepts which assert that power imbalances in sexual unions are explained by sexual division of labour sexual division of power and cathexis the interplay of these elements produces gender disparities and inequities that make women more vulnerable to their partners in their sexual and reproductive health 20 untill now men retain and control the factors of production in many african contexts women may therefore be subjugated to men reducing their ability to assert themselves in sexual unions in spite of these widely acknowledged power imbalances in sexual unions family planning programs have mostly neglected the influence of men and how they specifically shape the use nonuse and type of family planning discussions in sexual unions 13 rather family planning programs and research have focused mainly on women as the primary beneficiaries with less attention on men 2122 there is evidence to show that men specifically have and do use their influence on contraceptive use in sexual unions 2122 this influence is partly strengthened by ideologies of masculinity gender roles and beliefs existing in both patrilineal and matrilineal societies which allow men control over womens sexual and reproductive decisions and health 2324 studies on covert use of contraceptives are a sobering reminder of the power dynamics in sexual unions 1 male support for contraception may have an influence on womens contraceptive use types of contraceptive methods and types of modern contraceptive methods used evidence shows that partner support is associated with womens contraceptive use 101125 however results on the influence of partner support on the type of partners contraceptive method use are mixed whiles some studies have reported that partner support influences the use of modern contraceptive methods 826 other studies have reported the influence of men on traditional methods due to limited knowledge on modern contraceptive methods cost accessibility and side effects of modern contraceptives methods 181927 also some women conceal contraceptive use despite their partners disapproval to avoid tensions within relationships 152829 balogun et al 15 argued that there is an increase in modern contraceptive use when partners approve of contraceptive use for women though there are many studies on contraceptive use in ssa and ghana 12 30 31 32 few studies in the subregion and ghana have examined partner support and contraceptive use among urban poor women 103334 contextually the concomitant rise in africas urbanization and hivaids clarified the relationship between place and sexual activity on a broad population level deviating from the traditional development trajectories africas fast urbanization was not associated with economic development 3536 for accra like most capital cities on the african continent rapid population growth in urban centers was rather associated with deepening urban poverty for example while the levels of poverty had significantly reduced around the country in ghana urban poverty had intensified and widened research evidence from five african cities including accra shows how urban poverty elevated risky sexual behaviours 3536 particularly lower age at first sex low use of modern contraception and multiple sexual partners loose sexual unions typified by short term cohabitation another characteristic feature of urban poverty amplify the risky sexual behaviours within these areas 3536 in ghana studies on partner influence and contraceptive use especially among urban poor women are scarce 1237 there is no study comprehensively examining partner influence on current contraceptive use types of contraceptive methods and types of modern contraceptive methods among urban poor women urban poor communities are characterized by high poverty levels poor infrastructure and inadequate access to water and sanitation mostly urban poor families are large and this may affect the utilization of health care services including limited access to family planning options 38 in addition the disproportionately higher rates of unintended pregnancies in urban poor communities indicate that there is a high unmet need for family planning services 35 while there is overwhelming evidence to show how urban poverty influences sexuality in an urban poor context little is known about how partner support improves womens use of modern contraceptives understanding the influence of men on womens contraceptive use could help increase the uptake of contraception of women in ghana and prevent unwanted pregnancies among urban poor women also the inclusion of males in family planning programmes and policy could help address misconceptions and myths about partners attitudes toward contraception this study fills the gap in the literature by examining the influence of partner support in contraceptive use among urban poor women methods study design and setting the study utilized crosssectional household survey data which was conducted between january and july 2018 this was a collaboration between harvard th chan school of public health and the regional institute for population studies university of ghana the survey collected reproductive health information on women aged 1644 years residing in two study sites within urban poor communities in accra the first study site included the coastal communities of osu labadi teshie and nungua and the second included inland areas of madina ashongman and agboba the main economic activity for the communities along the coast is fishing whiles for the community inland it is sales and services the communities are characterized by low socioeconomic status and limited access to essential health services 3940 sampling procedure and data collection a multistage sampling method was used to create a representative sample of women in each of the two study sites the first stage involved the selection of clusters from equallysized subdivisions of census enumeration areas derived from the ghana statistical services census in the communities consisting of approximately 60 households 41 this was followed by a complete listing of all households in the selected clusters that included at least one eligible woman the second stage involved the random selection of approximately 25 households per cluster in which at least one eligible woman lived the third and final stage involved random selection of one woman within the household for an interview if more than one eligible woman resided there all women selected for the interview were introduced to the study by trained enumerators and their consent was sought participants who voluntarily provided written consent were enrolled in all 5836 households were initially sampled with 4952 women eligible for the study and 4184 consented to the study the questionnaire for the data collection consisted of individual and household characteristics individual reproduction family planning pregnancy marriage fertility preference and contraception and other healthrelated issues inclusion and exclusion criteria the inclusion criteria were women currently married and those in union aged 1644 years who lived in the study area at the time of the interview and could communicate in english or local languages for this study we further restricted the analysis to women who had ever used any contraceptive method and were currently married or in a union producing a final analytic sample of 1578 women women who were pregnant and those trying to be pregnant were excluded from the analysis they were excluded based on a series of questions during the survey the women were asked are you pregnant now and those who were not pregnant were asked do you want to get pregnant now based on the responses we were able to identify those who were pregnant and those trying to get pregnant ethical clearance ethical clearance for the study was obtained from the ethics review committee of the ghana health service the university of ghana ethics committee for the humanities and the harvard th chan school of public health institutional review board informed consent was obtained from each participant before they were interviewed all participants provided written informed consent to participate in the study the methods were carried out according to the guidelines specified and approved by the ethics committee the purpose of the study including the general objectives benefits and risks of taking part in the study were explained to the participants the participants were informed about the strict confidentiality and anonymity of their responses they were also informed about their right to stop participating in the study at any point if they desired to do so those who agreed to be part of the study signed an informed consent form and if they could not read or write they provided a thumbprint to participate in the study measurement of variables dependent variables the dependent variables for the study include 1 current use of any contraceptive method 2 type of current contraceptive method used and 3 type of current modern contraceptive method current use of any contraceptive method was defined as the use of any current family planning method measured as a dichotomous variable current users versus noncurrent user type of current contraceptive method was classified as a traditional method versus a modern method women who used withdrawal calendar and rhythm methods were grouped as traditional method while those who used iud implants injectable oral contraceptive pills emergency contraceptives condoms and lactational amenorrhea method were classified as modern contraceptive method users 37 the type of modern contraceptive method used was categorized into longacting reversible contraception and short term methods the larc methods comprised of iud and implants the shortterm methods included oral contraceptive pills condoms emergency contraceptives injectables and lam independent variable the independent variable for the study was a womans report of partner support in contraceptive related choices during the survey all women married or in union were asked does your husbandpartner support you in your choices related to contraceptive use with the response options yes and no women who had support from their partners were classified as yes and those with no support from their partners were classified as no control variables in addition other sociodemographic variables related to the outcome variables were included and controlled for these variables were included based on the literature review 8101219 the variables include age educational level religion employment status household wealth quintile ethnicity health decisionmaking children ever born partner illiteracy and family planning counselling age of women was coded as 1619 2024 2529 3034 3539 and 4044 the educational level of women was classified as level attained no education primary junior high school secondary and higher education religion was categorized as pentecostalcharismatic protestant orthodox other christians moslem and other religious affiliation employment status was classified as employed regardless of the sector either formal or informal and unemployed also the household wealth quintile was classified as poorest poorer middle richer and richest relative to the ghana demographic and health survey urban household wealth quintiles ethnicity was categorized as akan ga dangme ewe moledagbani and other ethnic groups health decisionmaking was grouped as respondents only husbandpartner only and husbandpartner jointly also children ever born was measured as a continuous variable receiving family planning counselling within the last two years at the health facility was classified as yes and no partner literacy was coded as yes and no in response to the question can your read a phrasesentence in english method of analysis stata version 15 was used for the analysis the data were analyzed at both the univariate and multivariate levels descriptive statistics such as frequency and percentage and mean and standard deviation were used to describe the proportion of each variable for categorical and continuous variables respectively binary logistic regression was used to examine the associations between partner support in contraceptiverelated choices and contraceptive use reported by women three separate models were fit to examine the associations between partner support and contraceptive behavior of women adjusted odds ratios and 95 confidence intervals were also used to describe and interpret the findings of the study a pvalue less than 005 was used for statistical significance and weighting was applied results description of background characteristics table 1 shows the background characteristics of women from table 1 about 829 women indicated that their partners supported their choices of contraceptive use while 171 reported that their partners did not support them in their contraceptive choices just over a quarter of the respondents were aged 3034 220 were aged 2529 and the smallest proportion were aged 16 17 18 19 with regards to education the majority of the women had at least junior high school education specifically a higher proportion of the women had junior high school education and about 125 had tertiary education slightly more than half of the women were affiliated to the pentecostal charismatic religious denominations and the least proportion 22 belong to other religious faiths about one third of the women belong to the akan ethnic group in addition only 264 belonged to the two poorest household wealth quintiles with regards to employment status about eight out of ten women reported being currently employed also slightly more than half of the women jointly took decisions with their partners regarding their health issues in addition nearly all women reported that their partnershusbands were literate description of dependent variables table 2 shows the description of the dependent variables slightly more than half of women currently reported using a method to prevent pregnancy about 581 of the women using any method were currently using modern contraceptive methods however the prevalence of modern contraceptive use among the general population was 258 from the subpopulation of women using any modern contraceptive method to prevent pregnancy the majority of them were using short term methods method types and partner support in contraceptive related choices table 3 shows the method types used by women depending on their partners support in contraceptiverelated choices the results show that the highest proportion of partners had no support for implants and the least proportion had no support for emergency contraceptives on the other hand most of the partners supported the use of the rhythm method while the least proportion of the partners support emergency contraceptives table 4 illustrates factors associated with contraceptive uptake among urban poor women who were marriedinunion in accra ghana the multivariate binary regression which adjusts for all other variables shows that partner support in contraceptive choices was significantly associated with current contraceptive use and modern method contraceptive use women who had support from their partners were more likely to currently use any contraceptive method than those with reportedly no support from their partnershusbands the odds of currently using a modern contraceptive method was lower for women who received support from their partners than those with no support in model 2 in addition when all other variables were controlled for in the model other variables that were associated with the current use of contraceptives were the age of women ethnicity of women household wealth quintile children ever born and health decision women who were 4044 years were less likely to currently use a contraceptive method compared to women aged 1619 years women belonging to the ewe ethnic group were more likely to be current users of contraceptives than women belonging to the akan ethnic group also women who belong to the middle household wealth quintile were more likely to be current users of any contraceptive method than those who belong to the poorest household wealth quintile also as the number of children by women increased the odds of women being a current user of any contraceptive method increased for decisionmaking women who take decisions on health with their partners were less likely to be current users of any contraceptive method relative to those who make decisions alone furthermore in model 2 ethnicity of women and decisions on health were associated with the current modern method of contraceptive use moledagbani women were more likely to currently use modern contraceptive methods compared to women belonging to the akan ethnic group in addition women belonging to other ethnic groups were more likely to currently use modern contraceptive methods compared to women belonging to the akan ethnic group women who jointly decide on their health with their partners were more likely to currently use modern contraceptive methods compared to women who take healthrelated decisions alone moreover only ethnicity of women was associated with currently using a modern longacting reversible contraceptive method after controlling for other variables in model 3 women belonging to gaadangme ethnic group were more likely to currently use modern longacting reversible contraceptive methods compared to women belonging to the akan ethnic group in addition women belonging to the ewe ethnic group were more likely to currently use modern longacting reversible contraceptive methods compared to women belonging to the akan ethnic group discussion drawing on crosssectional data among urban poor women in ghana this study examined the influence of husbandsmens support on their partners contraceptive use at different levels this study supports other evidence that shows the importance of men in womens contraceptive use and the need to include men in family planning programs previous studies have examined the influence of menshusbands support on contraceptive use and concluded that married women or women in union mostly require the support of their partners in contraceptive use 101315 most of these studies were not done in urban poor communities and do not provide insight on the influence of the complexity of contraceptive use by women at different levels this study contributes to knowledge by providing an understanding of the influence of husbands men on the almost stepwise progress of contraceptive use at different levels within urban poor communities in accra the results of this study highlight two main points for consideration by policymakers and researchers who are looking to address the unmet need for contraception and improve contraceptive uptake among married couples or women in union in the urban areas of ghana and similar contexts first in urban poor communities in ghana most women perceive that their partners support them in contraceptive use and this in turn is associated with not only womens actual use of contraceptives but also with the type of contraceptives they use secondly the support of husbands men in contraceptiverelated choices reduces the likelihood of women using modern contraceptive methods the findings of this study showed that husbandpartner support in contraceptiverelated choices are associated with the current use of any contraceptive method by women this is similar to findings of other studies 101315 which have reported partnerhusband support for contraceptive use the results imply that womens decision to use contraceptives was influenced by their partners involvement in decisionmaking the findings of the study may be supported by cultural and gendered norms where men have more decisionmaking power compared to women in reproductive issues this is most entrenched in urban poor communities where many women have low incomes low education and where there is no family support system to take decisions on their own which makes men the decisionmakers on reproductive health the findings of this study are also supported by the gender and power theory which argued that men have control over their partners sexual and reproductive health the control therefore determines the use of any contraceptive method by their partners also the power imbalance including the patriarchal system creates dominancy of men which enables them to exert control over their partners contraceptive choice most of the study communities are characterized by dominant masculinity norms which gives more power to men in reproductive health decisions including contraceptive use although some notions of femininity view pregnancy prevention within the domain of women ganle et al 24 argued that genderbased power imbalance and gender inequality give more power to men which limits womens autonomy women sometimes require permission from their husbands to utilize health care services in various parts of ghana as a result they may resort to covert use without their partners support this therefore underscores the power imbalance in unions also the results demonstrate that men have a preference for traditional methods of contraception compared to modern methods partners may prefer traditional contraceptive methods such as withdrawal and rhythm methods because it requires the joint participation of the couple in its use and is devoid of the side effects of modern methods reported by some women 18 furthermore from the mens perspective the use of traditional contraceptive methods could deter women from engaging in extramarital affairs mostly in urban poor settings for economic reasons in addition mens limited knowledge of modern contraceptives could explain their preference for traditional contraceptive methods this limited knowledge among urban poor people could account for false beliefs and mens fear of harmful side effects of modern contraceptives this is because men have limited access to contraceptive knowledge compared to women who are frequently exposed to the hospital environment during preand postnatal periods of pregnancy and childbirth 184243 in addition the cost of modern contraceptives could also account for the husbands preference for traditional methods and the deterrence of both the men and women from using modern contraceptives 1544 couples in urban poor communities who are mostly engaged in lowincome jobs may not be able to afford modern contraceptives such as iud implants and injectables due to their low socioeconomic background and may be forced to use traditional methods such as withdrawal and rhythm methods which are free these factors therefore do not provide a comprehensive understanding to inform husbands on modern contraceptives thereby limiting the use of modern contraceptives the findings of the study show that there was no significant difference between partner support in contraceptiverelated choices and the type of modern contraceptive method used the statistically nonsignificant results could be a result of the husbands preference for traditional methods or perhaps other factors that we did not examine in our study that is related to the decisionmaking around the type of modern method the results from this study illustrate perhaps a more nuanced understanding of how male support for contraceptive choices may influence their partners overall use but also determine the effectiveness of the method chosen the findings of this study are supported by the gender and power theory which explains that sexual division of labour sexual division of power and the structure of cathexis produce greater inequities between men and women these inequities make men exert a greater influence on their partners sexual and reproductive health in this study most men exert greater support on their partners contraceptiverelated choices and their influence determine the type of contraceptive that their partners use the power imbalances and the patriarchal system sometimes make it difficult for women to bargain or have dominion in their sexual and reproductive health thereby paving the way for men to exert an influence on their sexual and reproductive health this study is very relevant to the inclusion of men in family planning programs as the result shows that the support of men leads to the use of less effective family planning methods by their partners contraceptive related choices have consequences on increasing infertility as well as maternal morbidity and mortality due to unintended pregnancies the study is a crosssectional study hence causality could not be established findings from this study could inform policymakers to include men in family planning programs provision of family planning education needs to be strategized and information on family planning in urban poor settings should be intensified as policy targets men on family planning counselling conclusion the study contributes to understanding the influence of male partners in womens contraceptive use the results show that partner support influences womens current contraceptive use but less use of modern methods which are the most effective at preventing pregnancy the study highlights the need to involve men in family planning programs and research as well as educating them on the need to use modern contraceptive methods as it is more effective than traditional methods couples should be counselled on the management of contraceptive side effects as it may help to allay fears of debilitating side effects of modern contraceptives and to quell myths associated with modern contraceptive use there should be an improvement in accessibility of contraceptives in urban poor communities as well as improving on family planning education and information to increase uptake of modern contraceptives author contributions mwa egh mkk adod ca pa tt caa ish and aab conceptualized the study mwa egh mkk and adod analysed the data and wrote the manuscript mwa egh mkk adod ca pa tt caa ish and aab contributed to the data analyses interpretation of the data and reviewed the manuscript all authors read and approved the final version of the manuscript for submission competing interests the authors declare that they have no competing interest

background despite the benefits associated with contraceptive use there is a low prevalence of contraceptive use in subsaharan africa and ghana previous studies have partly and consistently attributed the low prevalence of contraceptive use to partner opposition however little is known about the influence of men in contraceptive related choices of their partners particularly within the context of urban poverty this study examines the influences of partners on womens contraceptive choicesthe study utilized a crosssectional household survey data of 1578 currently married women and women in a union of reproductive ages 1644 years women who were pregnant and those trying to be pregnant were excluded from the analysis the dependent variables for the study were current use of any contraceptive method types of contraceptive methods and types of modern contraceptive methods the independent variable for the study was a womans report of partner support in contraceptive related choices a binary logistic regression model was used to examine the associations between partner support in contraceptive related choices and contraceptive use of womenthe results of the study show that partner support of contraceptive related choices has a significant influence on contraceptive use of women women who indicated support from their partners were more likely to be current users of any contraceptive method yet were less likely to use modern contraceptive methodsthe study highlights the need to involve men in family planning programs and research as well as educating them on the various contraceptive modern methods and the side effects

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introduction estimates show that the number of people aged 60 and over is increasing globally specifically in 2017 the older population numbered 962 million an increase from 382 million in 1980 1 projections are that by 2030 and 2050 the older population will number 141 billion and 21 billion respectively 1 roughly twothirds of older people reside in countries in the less developed regions of the world including subsaharan africa not only are the economies of the countries of ssa inadequately positioned to contain this demographic tide but very little attention has been paid to issues of older people in this context promoting elderly wellbeing is key to human development and has been consistently featured in various development agendas such as the programme of action of the international conference on population and development the millennium development goals and quite recently the 2030 agenda for sustainable development 12 old age is characterized by an intricate mix of relationships and conditions older people compared to other population categories experience elevated levels of morbidity and functional impairment that affects their ability to live life meaningfully 13 in the specific case of ssa marked by immense health care access barriers evidence reveal high burden of chronic diseases and modifiable health risk factors among older adults in the region 3 4 5 furthermore older people compared to other age cohorts are at a much higher risk of poverty loneliness discrimination abuse and stigma 36 despite these challenges a considerable proportion of older people still remain economically active and employed contributing significantly to economic growth 34 more so older people remain a critical social support pillar especially in caring for grandchildren and other vulnerable members in their communities 47 of 15 previous empirical evidence attributes the situation of older people to a complex interaction between individualand structurallevel factors 8 9 10 11 12 for instance the functional and health status of older people determines their level of independence which in turn shapes their overall wellbeing 12 also household composition and the nature of social support structures determine resource availability and support for older people 4111314 this is particularly critical in settings like ghana with inadequate formal support systems along with weakening social ties declining household sizes and outmigration of adult children 1315 other important factors that define older adults conditions are economic status 16 available social security schemes 17 and geographic location 18 however the role of geography in constructing the everyday experiences of older people has been paid little attention in the literature which has implications for knowledge and efforts at promoting the wellbeing and quality of life of older people indeed over the past few decades human geographers have called to attention the importance of place and space in aging and old age outcomes 19 20 21 geographers engagement with questions of aging is done under the subfields of geographies of aging or geographies of older people and on the premise of a mutual and complex relationship between aging and the spaces and places within which it occurs 2122 thus experiences of old age including the coping strategies adopted are produced through complex interactions between structural and individual factors such as place of residence available support networks gender cultural norms and values economic conditions and the policy environment geography provides a useful and broad framework to examine and interpret the complex experiences of older people 1922 whereas geographic inquiry into aging is evident and dominant in the global north there is little engagement with the subdiscipline by researchers in ssa particularly ghana in a context delineated by considerable socioeconomic cultural and environmental disparities employing a geographic lens aids in contextualizing the complex and developing experiences of older people the rapidly changing ghanaian social and economic systems add an additional layer of complexity to the circumstances of older adults thereby meriting a geographic lens this study contributes to knowledge and policy practice by situating the everyday experiences of older adult ghanaians within the broader geographies of older people framework ghanas older adult population has increased rapidly over the years according to ghanas recent population and housing census people aged 60 and over constituted 67 of the countrys population in 2010 a rise from 45 in 1960 and is projected to double by 2050 8 with ghanaians now living longer it is important to pay attention to the situation of older people especially within research and policy spheres this will allow for the efficient allocation of resources for national development aging and ecological systems theory ecological perspectives which have gained considerable research and policy attention over the past three decades in the behavioral sciences assume that behavior has multiple levels of influence and that these influences interact across distinct levels 2324 in line with this ecological perspectives emphasize the need for multilevel interventions in changing human behaviors in this study we adopt the ecological systems theory proposed by bronfenbrenner to situate the lived experiences of older people in their social and physical contexts this theoretical construct allows for a broader interrogation and understanding of the human environment as an agent of development bronfenbrenner views the environment as a nested arrangement of structures each contained within the next 25 based on this conception five levels of the human environment need to be considered drawing from this perspective we view aging as a complex process affected by and affecting different levels of the social and physical environments at the center of the theory is the developing person which in the context of this study is the growing older person and their personal characteristics the microsystem the first level comprises the older person and their immediate environment and all interactions between them this includes older peoples physical surroundings such as the home and workplace previous studies in ghana and beyond have highlighted the usefulness of microsystem factors in constructing the experiences of older people 2627 a mesosystem involves the interconnections among the major settings in which older people are found at any point in their life among older people their mesosytem include interactions among family peers church and workplace the exosystem is an extension of the mesosystem and involves structures that do not themselves contain developing older persons but impact the settings containing them these structures can be formal or informal and include neighborhoods mass media government institutions and government policies amegbor and colleagues draw attention to the relevance of neighborhood environment in defining the mental wellbeing of older people in ghana 11 they found neighborhood safety and structural social capital to reduce the likelihood of depression among older adults the macrosystems encompass the overarching institutional patterns of the culture or subculture such as the economic social educational legal and political systems of which micro meso and exosystems are the concrete manifestations 25 the macrosystem borders on the ideologies of a group that shape behaviors and relationships the chronosystem a level added later involves all the experiences of individuals over the course of their lives the complexities of aging require a theoretical perspective that considers the different and interconnected influences of the environment ecological systems theory coupled with perspectives from the geographies of older people therefore provides a theoretical advantage in situating the everyday experiences of older people within prevailing social economic political and environmental contexts these frameworks also provide the positional space to develop and implement appropriate intervention programs to improve the wellbeing of older people in ghana earlier researchers have applied ecological systems theory to investigate various social phenomena among vulnerable groups in ghana for instance yendork used ecological systems theory to explore the different vulnerabilities associated with orphanhood in the ghanaian context 28 also agyeiokyere and colleagues drew on ecological systems theory to examine the living conditions of disabled people in mining communities concluding that participants interactions with the environment produced unbearable hardships 29 however no study to the best of our knowledge has utilized this perspective in exploring the experiences of older people in ghana materials and methods study design this study employed a qualitative research design involving interviews and sharing circles to understand the experiences of older adults in ghana interviewing as a data collection technique explores individuals views experiences andor beliefs about a phenomenon 3031 interviewing has been touted for its flexibility and effectiveness in unearthing peoples experiences and the meanings they attach to these experiences sharing circles on the other hand are open conversations involving the sharing of stories and life experiences of people within a particular cultural setting 3233 rooted in indigenous epistemologies and ways of understanding the world sharing circles have emerged as a vital research tool in conducting research in indigenous communities within europe and north america 34 a combination of these two qualitative data collection techniques is appropriate to unearth the complex experiences of older people in a natural and culturally appropriate manner the consolidated criteria for reporting qualitative research proposed by tong and colleagues was utilized in reporting our findings 35 coreq is a tool developed to aid in the explicit and comprehensive reportage of qualitative findings 35 research team and reflexivity interviews were conducted by the lead author a doctoral student who identifies as a male and hails from the upper west region of ghana no participant had prior relationship with the lead author who conducted the interviews with the support of trained research assistants and community leaders though in navigating language barriers we recruited research assistants from the area they had no relationship or contact with participants the coauthor is the lead authors doctoral supervisor who has no contact with the participants mwr is a human geographer with interests in health and health service use aging and population studies among others employing both qualitative and quantitative research techniques the assumptions of the researchers going into this study were that old age experiences in ghana are diverse and produced by the complex interaction of individual and structural factors this research contributes to the gerontology literature by illuminating the lived experiences of older adults in ghana the study further provides evidence for relevant policy decisionmaking in ghana and similar contexts study setting the upper west bono east and greater accra regions of ghana were selected for this study these regions were purposively selected to represent the three major ecological zones in ghana data collection took place from june to august 2019 ghanas most recent population census reports that the older population constitutes 67 of the estimated 25 million people in the country 36 of the total number of older people the greater accra region has the largest proportion with the brong ahafo and upper west regions constituting 87 and 36 respectively 8 the consolidated criteria for reporting qualitative research proposed by tong and colleagues was utilized in reporting our findings 35 coreq is a tool developed to aid in the explicit and comprehensive reportage of qualitative findings 35 research team and reflexivity interviews were conducted by the lead author a doctoral student who identifies as a male and hails from the upper west region of ghana no participant had prior relationship with the lead author who conducted the interviews with the support of trained research assistants and community leaders though in navigating language barriers we recruited research assistants from the area they had no relationship or contact with participants the coauthor is the lead authors doctoral supervisor who has no contact with the participants mwr is a human geographer with interests in health and health service use aging and population studies among others employing both qualitative and quantitative research techniques the assumptions of the researchers going into this study were that old age experiences in ghana are diverse and produced by the complex interaction of individual and structural factors this research contributes to the gerontology literature by illuminating the lived experiences of older adults in ghana the study further provides evidence for relevant policy decisionmaking in ghana and similar contexts study setting the upper west bono east and greater accra regions of ghana were selected for this study these regions were purposively selected to represent the three major ecological zones in ghana data collection took place from june to august 2019 ghanas most recent population census reports that the older population constitutes 67 of the estimated 25 million people in the country 36 of the total number of older people the greater accra region has the largest proportion with the brong ahafo and upper west regions constituting 87 and 36 respectively 8 substantial socioeconomic variations exist across these ecological zones and between urban and rural areas which are crucial for understanding peoples lived experiences 837 reasons for these variations are political environmental and sociocultural for example precolonial and current governmental policies led to more development in the coastal and forest zones than the savannah zone 38 poverty incidence in the greater accra region is way below the national average and above average in the brong ahafo and upper west regions 39 doctor to population ratios in 2017 were highest in the greater accra region followed by the brong ahafo region and the upper west region 40 compared to urban areas rural areas in ghana where the majority of older people reside are underdeveloped and lack basic amenities including health facilities electricity potable water and sanitation services 37 in addition to outnumbering their male counterparts possibly due to their higher life expectancies older women are socioeconomically disadvantaged and continue to play productive and reproductive roles including providing care for grandchildren and other vulnerable household members 337 outmigration is a common phenomenon in ghana involving mostly younger adults in rural areas and the savannah ecological zone in search of better livelihood opportunities 41 religion forms an integral part of life in ghana with 9 out of 10 older ghanaians being religious over half of ghanas older population are economically active constituting an estimated 86 of the countrys labor force 8 an overwhelming majority of these economically active old people are employed predominantly in the agricultural and forestry sectors 8 a little over half of the older population are married illiterate and household heads with 12 of them being disable 8 about a quarter of houses occupied by older people do not have toilet facilities 8 in july 2010 ghana adopted a policy on aging to bring to the fore issues confronting the older population 817 additionally the national health insurance scheme and the livelihood empowerment against poverty program recognizing the needs of the older population provide free medical insurance and cash grants to some needy older people in the country 642 these policy interventions have however been decried for being inadequate and incomprehensive 6 the study communities chosen in the context of the national and regional situation were la nkwantang municipal and ningoprampram district in the greater accra region techiman and nkoranza south municipalities in the bono east region and wa west and sissala east districts in the upper west region sampling and recruitment a purposive sampling technique was used to recruit research communities and participants purposive sampling involves the selection of participants because they possess certain characteristic necessary for detail exploration of a particular theme or research question this ensures that all relevant participants are included in the study which allows for the exploration of diverse perspectives on a topic interviews commenced with contacting gatekeepers of selected communities who in most cases were assembly members the gatekeepers then assisted the research team to identify and contact potential participants the scope of the study was explained to participants and interviews scheduled six participants however could not make it to the interview due to illhealth and other personal reasons in situations where a participant could not participate efforts were made to find a replacement with similar characteristics the sharing circles also commenced with contacting the gatekeepers of selected communities who were subsequently briefed on the study we then asked for their assistance to recruit participants we also sought information on knowledge acquisition protocols in the communities from these gatekeepers followup visits were made a few days later for updates further consultation and scheduling the visits also aided in building rapport with our research participants even though group membership was decided by the community we ensured they fell within the target population the number of participants in the group was decided by the community the minimum and maximum number of participants in the sharing circles were 6 and 10 respectively data collection interviews were conducted facetoface in twi sissali dagaare brifo ga or english at participants preferred locations through this participants were comfortable sharing their stories and experiences interviews were semistructured semistructured interviewing is a data collection technique with a predetermined order that also allows for divergence to explore an idea in detail 43 our interview guide comprised openended questions the guide was developed by the research team based on the research objectives comprising two main sections the guide was pretested among four participants and refined to fit the study the first section focused on older peoples understanding of aging the second part centered on their experiences the first author conducted all interviews with support from trained research assistants and gatekeepers the interviews lasted between 20 and 40 min and were audiorecorded with permission from participants a total of 42 interviews were conducted ten sharing circles were conductedfive each in the upper west and bono east regions an urban and rural community were selected from each of these two regions for the sharing circles three meetings were held in each rural area comprising an allmale an allfemale and a mixed one for each urban area we conducted two meetings comprising an allmale group and an allfemale group we developed a guide for the sharing circles based on the study objectives a participant was selected from each group to facilitate the discussion sharing circles lasted two hours on average and were audiorecorded with permission from the participants our sample sizes were defined by information power 44 the authors suggest that an adequate sample size for any study is determined by the aim sample specificity theoretical approach quality of dialogue and analytic strategy we also collected field notes to reflect on complement and contextualize our data each participant was given 10 ghana cedis for their time for some sharing circles kola nuts were provided in accordance with customs data management analysis and rigour interviews were translated and transcribed by the first author and two professional transcribers for each interview transcript two other persons proficient in the language were contracted to compare the transcripts with the corresponding audio file two other local researchers were asked to randomly sample and compare transcripts with audio recordings this was done to maintain meaning and ensure rigor transcripts were then imported into nvivo™12 qualitative data analysis software for analysis following braun and clarke the lead author read all the transcripts repeatedly to familiarize himself with the data while noting key themes which was done both deductively and inductively 45 we then proceeded to generate codes systematically after which codes were organized into themes and subthemes finally the themes and subthemes were mapped to the different systems of the environment proposed by bronfenbrenner transcripts from each data source were coded by the lead author and subsequently by another researcher to ensure reliability differences in coding were discussed and resolved over 70 agreement was achieved for both interviews and sharing circles 46 triangulation of the findings was done across the two data sets we facilitated the credibility of this study by consistently using interview guides during the interview process we also used professional transcribers and crosschecked interview transcripts additionally we used qualitative data analysis software ethics research ethical protocols were duly observed in terms of procedural ethics the study received clearance from the queens university general research ethics board beyond the procedural ethics culturally defined situational relational and exiting ethical protocols were duly followed written and thumbprint consents were obtained from participants after they were briefed and had all of their questions answered participants were assured of confidentiality and those in the sharing circles admonished to remain confidential about what others had said to protect participants identities we use pseudonyms in presenting quotes key participant identifiers have also been excluded from the results results participant characteristics participant characteristics are presented in tables 1 and2 our interview participants were almost evenly distributed between females and males and rural and urban areas additionally about half of participants were aged 6069 had no education and with household size below 6 akin to the interviews our sharing circles participants were almost evenly distributed between females and males also the majority of participants were aged 6069 had no education and lived in rural areas participants experiences this section presents participants experiences participants pseudonyms gender and region of residence are associated with quotes social support and loneliness access to support was a recurring theme in the interviews consistent with ghanas social support landscape participants narrations largely bordered around informal support which encompasses unpaid assistance from family friends neighbors and other community members we found divergent support experiences with most participants explaining that they lacked assistance with daily living tasks such as washing cooking sweeping and shopping in the words of a participant there is no support i do not have any helper and due to my sickness its difficult to perform daily tasks even getting someone to help prepare food is a problem my clothes are always dirty more older men than women were concerned about the lack of assistance in carrying out these tasks and this is potentially a reflection of prevailing discriminatory cultural norms where women are ascribed such domestic roles a number of reasons were cited for the lack of support key among them is the outmigration of adult children this theme was more common among participants from the northern and middle belts of the country and those in rural areas a few participants blamed the lack of support on the demise of their adult children and partners social and economic transformations were also acknowledged as barriers to social support a participant had this to say some changes have occurred those days people sympathized with older people the younger generations assisted the older ones regardless of who they are now it is not the case they do not care about us anymore the general practice and expectation are that older persons are cared for by informal networks especially adult children akin to this expectation a few rural and female participants admitted receiving support from their networks as highlighted in this participants testimony my children care for me they can never leave me to go hungry i carried them in my stomach for several months and took care of them when they were young and its their turn now albeit limited nonkin also play a crucial role in providing support for older people especially those lacking assistance from family members as expressed by a participant i get food to eat someone nonkin gave me yam yesterday i really do not have a problem with food in my church they visit the elderly occasionally to help there is another church in this area every month they bring the elderly together to share the word of god and feed them it was observed that intangible support particularly emotional support was less of a concern to participants a common issue that imbued discussions on social support was how the lack of assistance negatively affects health and wellbeing many participants noted engaging in health compromising activities to survive for some they were constantly worried and had sleepless nights about where their next help will come from the lack of support participants explained had the potential to lead them to their early graves some participants also reported experiencing loneliness experiences of loneliness were common among male participants and those living in urban areas where social cohesion appears weak when asked about support from formal sources it was apparent very limited assistance was available as many of them were oblivious of the existence of such services a number of participants especially rural folks and those from the upper west region reported receiving cash support under the leap program some participants were also exempted from paying health insurance premiums as part of governments efforts to improve health care access in ghana participants decried however that these support services are limited and highly politicized social status old age in traditional ghanaian society is generally associated with improved social status and authority some participants reported elevated status and authority at this stage of their lives some of them have been conferred leadership roles including household clan and spiritual headships i am the head of the section and every morning they come to greet i own the land here and make decisions payment of dowry is done in my house and when it comes to sharing resources i receive first it is the norm these ascribed statuses are also useful in expanding conferees social capital as an elder i am respected and can ask for assistance from any one in my community at harvest i receive food stuffs from people where i live now was put up for me as the head discussions of ascribed status and authority however reflects gender and socioeconomic disparities with females and poorer individuals recounting lower social status they reported frequent discrimination stigma and abuse a participant had this to say some young ones say it to me that i am a witch i am a witch because all my siblings are dead and i am the only one left but i am innocent i do not know how and what witchcraft is one of my nephews even left the community because of that in the words of another participant we are the most abused and disrespected ones in this community we are seen as liabilities no one respects us we get insulted all the time and if you are not careful can even be beaten functional restriction and poor health and health service access a recurring theme in the interviews and sharing circles was poor health and functional impairment notable health conditions included body pains diabetes high blood pressure arthritis and hypertension these conditions considerably limit their independence and ability to engage in livelihood activities they were often referred to as aging sickness today you feel pains here tomorrow you feel it somewhere else you go to the hospital and you are told its menopause personally i am always ill there are times i could not walk because my legs were hurting every month i go to the hospital for checkups although many participants reported seeking formal health care service numerous access barriers exist several participants were not eligible for free health care under the national health insurance program as only individuals that are 70 years and over have coverage the nonavailability of geriatric care services and associated financial implications were also notable barriers to health service use more concerning was the fact that many of those who reported aging sickness were ineligible for financing under the nhis the difference that access to health insurance makes and how it differentiates older people in our study is illustrated in the quote below by the grace of god this nhis card has made things a bit easier although it does not cover a lot of the medications i do not work due to my age and if i start to feel pains in any part of my body instead of me going to the hospital i would not in addition to financial barriers participants in rural areas expressed concerns about geographical barriers to accessing health care with many of them lamenting having to travel longer distances to access health care services others identified discrimination at the health facilities explaining that it prevents them from seeking health care services the inability to access formal health care services often precipitated selfmedication and the use of traditional medicines among participants food insecurity food insecurity was another concern among participants particularly those in the upper west and bono east regions where livelihoods heavily depend on agriculture participants lamented going several days without food and when available how it was insufficient and lacked relevant nutrients previously i eat the kind of food i want to eat but now i do not have money so whatever my children get for me is what i will eat at this age it is all about management sometimes you can go the whole day without food you have to wait for them to return from the farm before you can get something to eat although some older people engage in livelihood activities to meet their nutritional needs in part returns from these activities are often insufficient older people in agriculture for instance complained of climate change threats high input cost and low crop yields we rely on farming to feed but these days yields are very low and when that happens your feeding is affected inputs are very expensive to come by our land is now accustomed to fertilizer to survive one must reduce the quantity of meals some participants reported employing food management strategies such as skipping meals reducing meal quantities and eliminating certain food groups from their diets just as you mentioned earlier maybe with the 30 ghana cedis i have eating banku will prevent me from getting food tomorrow even if i want to take the banku i cannot sometimes i go a whole week without taking meat but the truth is that when you get to a point in life you cannot eat everything you want others begged for food to feed the lack of consistent access to food was acknowledged to negatively affect their mental and physical health economic insecurity linked to food insecurity participants also complained about economic insecurity most participants were economically inactive and without pension benefits income support from formal institutions was reported to be limited to a few rural and indigent older people grant amounts were also noted to be small an old man on the leap program described his cash grant as pitiful economic insecurity does not only hinder participants access to nutritional diets but it also impedes health care service use especially among rural dwellers who in many situations have to travel to access health care they do not use it during kufuors era you do not have to pay for anything when you come to the hospital with the health insurance but now when i renew my insurance i have to pay gh 5000 many participants lacked collaterals to secure loans the inability to secure loans considerably affects participants negatively especially their ability to engage in livelihood activities a few capable older people in maintaining livelihoods however were engaged in some economic activities such as trading operating food joints farming rearing brewing pito shea nut picking and processing charcoal burning and sewing undertaking these activities is however not without barriers commodities especially food from older people are less patronized undertaking these livelihood activities is also physically demanding and health compromising i sew dresses but my sight is now failing me also as you age patronage declines you are seen as old fashion 426 inadequate access to water and sanitation services experiences with accessing water and sanitation services was also discussed akin to the general population access to water and sanitation services was a challenge to participants water access challenges were however gendered with older women and urban dwellers being the worse affected rural older woman for instance trekked longer distance to draw water water access challenges in urban areas had to do with irregular supply and cost the water quality was sometimes poor in terms of access to sanitation services a participant had this to say getting a place of convenience is a challenge its a public one and you will have to squat it can be challenging it is dirty and smelly we pay to use it too older rural residents also lamented walking longer distances at the mercy of the weather and snakes to openly defecate a participant noted it was a common occurrence for them to improvise with containers during such periods and dispose of it later caregiving and associated burden participants raised concerns about providing care for some household members especially grandchildren left behind lamenting that it takes a heavy toll on their health and finances caregiving was highly gendered with older women in our sample much more involved than older men notably caregiving activities included feeding bathing clothing and payment of school fees whereas some migrant children remit to support participants care for people left behind such remittances are often irregular and inadequate an old woman who cared for three grandchildren described it as the worst experience in her life in her words when you are young and energetic you have no problem even 10 children can be taken care of but at this stage its a big punishment two of them cannot bath by themselves i have to cook for them paying their fee is also a problem i cant sleep at night and i wonder what will happen to them when i die discussion ghanas older population has witnessed a steady increase over the past decades in the face of considerable social economic and environmental transformations 3847 however there has been very little attention to the circumstances of older people in this context particularly how their everyday experiences are situated within the broader geographies of health this study contributes to the discourse on the geographies of older people by exploring the everyday experience of older people in ghana our findings fit within the literature on geographies of older people and confirms the enduring view that older adults experiences are complex gendered and geographically variable 27 48 49 50 findings from this paper demonstrate the need to contextualize the experiences of older people within broader social economic political and environmental settings at the microsystem level we discovered that participants face challenges with instrumental activities of daily living particularly meal preparation drawing water household cleaning shopping and toileting these challenges can be attributed to a decline in their functional ability and health status conditions which were overwhelmingly reported by study participants earlier studies have reported similar challenges among older adults 427 the findings also revealed gender disparities in participants experiences in all situations except for performing most of the instrumental activities of daily living older women appeared worse off older women mainly remained restricted to household spaces performing various domestic duties such as caregiving cooking and cleaning they also were discriminated against and abused more than their male counterparts this is in line with the findings by 50 that the situation of older women in ghana is characterized by poverty and abuse explanations for these disparities can be found in the lower economic status of women and discriminatory cultural norms that ascribe women domestic roles in ghana even though poverty is widespread urban dwellers appeared to carry the heaviest burden possibly due to the relatively higher cost of living in urban areas compared to the rural areas consistent with other studies poverty was found to negatively affect the mental and physical health of older people 316 at the mesosytem which encompasses the system of microsystems we found mixed experiences among participants in the support they receive and their social status an overwhelming majority of participants lacked social support despite the centrality of social support to the wellbeing of individuals 11 this is concerning in the context of ghana where formal support programs are limited earlier research in ghana and related settings have made similar observations attributing the lack of support for older people to a number of interrelated factors including weakening social ties changing household structures declining family sizes economic challenges and migration of adult children 71527 in contrast a few participants reported receiving assistance which may be due to their access to supportive social networks in line with previous studies some participants also carried the burden of providing care for household members especially grandchildren 37 participants place of residence was also found to influence their overall experiences rural dwellers had more access to social support than their urban counterparts suggesting that stronger social ties are more likely in rural than urban areas more so values that emphasize filial piety might be stronger in rural areas than urban areas however participants from urban areas and the greater accra region had better access to health care services food and sanitation services better infrastructural development coupled with better economic conditions in urban areas in ghana possibly explain these experiences 37 these findings highlight the role of space in constructing aging experiences and feed into broader discourse on geographies of rural areas at the exosystem there was consensus that the central government has the duty to provide support services for older people in line with this expectation the government of ghana introduced a number of propoor initiatives to improve the wellbeing of older people similar to many antipoverty initiatives in ghana we found that these programs made minimal impact in improving the economic status of older people very few participants reported receiving financial assistance under the leap program likewise not only are people under the age of 70 ineligible for free enrolment but also a lot of health problems faced by older people were not covered by the nhis this finding corroborates earlier studies on the topic in ghana 31751 the effects of climate change on farming systems emerged as an important concern for participants especially those in rural areas and the upper west and bono east regions where livelihoods heavily depend on agriculture this finding is consistent with previous studies that have highlighted the negative impacts of changing climate on livelihoods in ghana 5253 other reported challenges at the exosystem level are the lack of health care facilities water and sanitation services and economic opportunities which adversely affect participants wellbeing and quality of life 616 participants experiences at the macrosystem center on cultural norms and beliefs cultural norms and beliefs give meaning to aging and influence relationships and experiences of older people these beliefs and norms also frame interactions within other domains of the environment in line with prevailing cultural norms older women expressed concerns about the lack of autonomy and access to communal resources some women farmers had challenges accessing farmlands women were commonly accused of witchcraft we also noted that participants willingness to seek support especially from nonkin members was influenced by their world views this study has a number of strengths and limitations theoretically the study demonstrates the applicability of ecological systems theory and perspectives from the geographies of older people in investigating the experiences of older people through this we were able to illustrate how various individualand structurallevel factors interact to produce the everyday experiences of older people the findings also augment the literature on older people in ghana and more broadly in the african subregion where research attention to older people is minimal the use of sharing circles together with interviews allowed for the collection of data in a more indepth natural and culturally sensitive manner this study is among the first to collect data using sharing circles in the context of a developing country with regards to limitations the findings are a presentation of the dominant subjective views of a small sample of older people and hence should be interpreted with caution also in this study like most qualitative studies there is the possibility of the meaning being lost during the translation of the results we however minimized the possibility of such biases by involving several people fluent in the local languages to transcribe and validate transcripts conclusions this paper draws on the geographies of older people literature and ecological systems theory to illustrate how older peoples individual characteristics intersect with their social and physical environments to construct and give meaning to their lived experiences we conclude that the experiences of older people in ghana are complex and produced by social economic environmental and political systems future studies can contribute to knowledge by drawing from geographic perspectives to explore specific concerns of older people such as food insecurity health services access economic insecurity and caregiver migration and its impacts the findings demonstrate the need to scaleup existing social protection initiatives to meet the needs of older people this can be achieved by making adequate budgetary allocations to these funds and relevant institutions also the eligibility criteria for these programs needs to be revised to cover all older people in need communitybased social protection programs may also be instrumental to enhancing the wellbeing of older people the provision of geriatric care services needs to be incorporated into the public health system and more health professional trained to provide such services given their heavy dependence on social networks it would be beneficial to build stronger social and community networks to support older adults efforts should also be made to improve the economic status of older people for instance given the increasing life expectancy in ghana age of retirement could be revised to enable individuals over 60 years capable and willing to work to remain in the labor force there is also the need for the disbarment of existing discriminatory cultural norms that disadvantage older women although efforts have been made by the central government over the years to improve the wellbeing of older people in ghana our findings reveal they still face numerous challenges thus promoting the wellbeing of older people must still be a top priority if ghana is committed to meeting the 2030 agenda for sustainable development data availability statement not applicable institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki and approved by the general research ethics board of queens university kingston canada informed consent statement informed consent was obtained from all participants involved in the study

while existing research acknowledges copious challenges faced by older adults people aged 60 and over in ghana and most countries in subsaharan africa they fail to situate the lived experiences of this vulnerable group within the broader context of health geography and public health this paper draws insights from ecological systems theory and the geographies of older people literature to examine the lived experiences of older people in ghana data for the study were gathered using interviews 42 and sharing circles 10 our findings reveal a complex mix of experiences consistent with the different levels of the environment dominant themes include access to social support functional impairment and poor health status social status poor access to water and sanitation services food insecurity economic insecurity and caregiving burden these findings support the wideheld notion that the experiences of older people are complex and produced by the interplay of both individual and structural factors our findings demonstrate that sociocultural economic political and climatic factors are important consideration in promoting elderly wellbeing and quality of life in ghana

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background peer workers are used extensively in hiv prevention activities targeting female sex workers as fsws who themselves fall in a highrisk group interventions assume peer workers to be most capable of delivering desired hiv services using a case study of the implementation of a community mobilisation intervention to address hiv risk among fsws in india we demonstrate that peer workers do not simply educate fsws about behaviours that can put them at risk of hiv they also act as community organisers who mobilise their peers to change their risk environment we develop this argument by focusing on the change in the function of peer workers in nongovernmental organisations implementing an hiv prevention intervention the interventions approach transitioned from an implicit model of communityled structural intervention to a more traditional targeted intervention while continuing to use the language of community mobilization we discuss how these two approaches are reflected in the work of peer workers the literature on community mobilisation interventions underscores the importance of collectivization and empowerment strategies for hiv prevention programmes targeting fsws in these programmes community mobilisation takes on such varied forms as running a 24hour crisis response campaigning for social entitlements building communitybased organisations and stakeholder advocacy interventions using peer workers and community mobilisation approaches are positively associated with outcomes related to hiv prevention such as improved knowledge about condoms reported increased condom use with clients and reduced incidence of sexually transmitted infections barring exceptions the evidence reveals little about the context in which peer workers mobilise fsws and how they overcome challenges to initiate and sustain community mobilisation interventions we contend that understanding implementation is important because it reveals conditions that make community mobilisation a distinct approach for hiv prevention among fsws the case study for this paper an hiv prevention programme among fsws implemented as part of the bill melinda gates foundation supported avahan india aids initiative is an example of an approach characterised by peer education and community mobilisation within a clsi framework the avahan package of prevention interventions used peer workersselfidentified women who exchanged sex for money who had leadership qualities and strong links to the fsw communityto reach out to members of their social networks who were at risk of hiv they provided support and information to negotiate condom use distributed free condoms and encouraged fsw attendance at sti clinics and other community programmes they mobilised fsws to strengthen their collective agency and advocate with stakeholders to secure an enabling environment in 2008 avahan initiated a planned transition primarily involving the transfer of funding and management of its hiv prevention interventions to the indian government the expected outcome was that the governments national aids control organisation would finance and monitor the hiv prevention intervention to be implemented by cbos organisations whose membership comprised community members or fsws in this case cbos would be supported by ngos organisations whose workers are not necessarily community members but who are able to provide the cbos with the technical expertise to run an intervention albeit with fewer financial resources than were previously available when funded by the bmgf instead of realising this vision the transition essentially separated the intervention into two distinct phases the intervention that preceded transition represented a clsi approach to hiv prevention with detailed attention to local context where peers worked as community organisers to change conditions in the social environment that shaped the hiv risk of fsws what followed the transition was a ti approach characterised by peer outreach to fsws with greater attention to giving condom use and sti clinic information and less attention on community mobilisation collectivisation and forming of cbos the purpose of this paper is to provide a comparative ethnographic account of the work of peer workers in an hiv prevention programme for fsws that started first as a clsi and transitioned into a ti we demonstrate the ways in which the changes following transition influenced not only the functionality of peer workers but also the meanings and avenues for community participation we discuss the implications of these interventions for effective community mobilisation around hiv prevention our analysis is focused on peer workers as their work reveals the underlying assumptions about the sources of hiv risk among fsws and the types of interventions necessary to address them study site methods and data sources the data for this paper are drawn from work done by project parivartan a multimethod study supported by the bmgf to analyse the implementation and impact of community mobilisation interventions to reduce vulnerability and hiv risk among fsws from the end of 2004 through mid2007 four rajahmundrybased ethnographers spent time at an ngo that was responsible for implementing the intervention in and around rajahmundry city in the east godavari district of andhra pradesh state in southern india for the ti phase from mid2007 through the end of 2012 in addition to the east godavari sites we expanded our research to ngos implementing the intervention in and around nellore and guntur towns in the eponymously named districts in andhra pradesh we draw on multiple data sources over an eightyear period covering the clsi and ti phases of the intervention clsi phase we used ethnographic data in the clsi phase including informal conversations with peer workers 22 observations of peer worker monthly meetings and 40 observations of the cbo leadership group meetings at the side lines of these meetings we had informal conversations with fsws peer workers and ngo staff about different aspects of implementing the intervention in this phase we held two rounds of formal interviews at our research site office with purposively selected fsws peer workers and cbo leaders about their work and about the cbos involvement in implementing the intervention participants provided verbal informed consent before the start of the interviews and were compensated a nominal amount to cover transportation costs study procedures were conducted in the local language the interviews were audiorecorded and summary reports of the audiorecordings were used in this analysis ti phase for the ti phase data are drawn from 28 observations of peer worker and intervention staff meetings we used informal conversations with peer workers intervention managers supervisors of peer workers and the staff of district sti clinics government hospitals and hiv testing centres additionally we draw on 20 informal conversations with cbo leaders informal conversations guided by broad questions about intervention implementation were held at the side lines of meetings we observed during time spent at ngocbo offices and government health facilities and when we met people in public places these conversations were not audiotaped and participants were not compensated monetarily ethnographers wrote detailed field notes of these conversations at the end of each day we also draw on eight records of research team meetings two authors supervised data collection in both phases ethical approval was obtained at the institutional review boards of yale university duke university american university and through yrg care a research institution in india following the principles of content analysis one author read all the ti data identified emerging themes and coded the data using nvivo all authors periodically discussed emerging interconnections between codes and themes next one author read the clsi data viewing the information from the codes and themes that emerged from the ti data similarities and differences within and across intervention phases were analysed all authors discussed these themes at several meetings to reach a consensus on the emerging findings of this comparative analysis the strength of our methodology is that we analysed what is unique about the clsi intervention by focusing on the differences that were revealed when the intervention transitioned to a more traditional ti approach specifically focusing on differences in the function of peer workers findings an analysis of the work of peer workers as the intervention shifted from clsi to ti reveals critical differences between a clsi and a ti approach to hiv prevention we focus on four distinct areas of difference assumptions about the conditions that produce hiv risk degree of emphasis placed on the work of collective mobilising and building collective power extent to which community mobilisation and hiv prevention goals are linked and the interventions use of peer input assumptions about the conditions that produce hiv risk in the clsi phase peer workers organised fsws to address a range of conditions that produced hiv risk whereas in the ti phase they provided hiv prevention information to fsws and motivated them to adopt safe practices these differences signal the differing strategies adopted by the clsi and ti approaches as well as the different roles of peer workers within each approach in the clsi approach peers were designated as social change agents and conceptualised as nucleus of strength in the community for bringing social change started by the community … related to human rights legal rights … empowered to act as a torch bearer in the struggle for emancipation of the community … and advocate for them and fight against all oppressions and atrocities three years into the intervention peer workers said they not only distributed condoms brought sex workers to the clinic and provided fsws information about hivaids and stds but also helped sex workers deal with police interactions spoke to district officials to obtain ration cards and housing sites for fsws advised fsws about saving money and represented fsw interests at meetings of specialised committees setup by the ngorun intervention fsws also said that peer workers were … working hard for our welfare … trying to decrease humiliation about sex work and create respect for us in public in the ti approach the designation social change agent was replaced with peer educator which was used across all intervention sites the function of peer workers was defined as providing information on hiv stis and harm reduction and promoting condom use among colleagues and peers which ultimately resulted in building peer pressure for behaviour change they can also distribute condoms lubricants … and provide basic data for monitoring the project using this frame the range of activities undertaken by the peer workers narrowed community mobilisation continued to be featured in discourse as a central component of the ti approach yet our data indicate that the intervention focused most of its attention on achieving predetermined targets as set by the government observations revealed that the better part of peer worker meeting times was spent holding peers accountable for the achievement of such predetermined targets including numbers of fsws contacted taken for clinical services and registered as cbo members in addition to the number of free and subsidised condoms distributed through social marketing field notes indicated that when weekly meetings listed other agenda items such as peer worker response to violence or collection of cbo membership fees there was typically scant discussion of these issues degree of emphasis on collective mobilising and building collective power in line with their mandate for social change peer workers in the clsi approach mobilised fsws to work collectively to address shared problems this attention to rework power relations was not emphasised in the ti approach for instance the clsi intervention formed a crisis intervention team comprising intervention staff and peer workers using various strategies to leverage the cbos collective power to lead sustained action against police violence and harassment similarly at large public events peer workers used their collective power to address the stigma attached to sex workers field notes from the clsi phase indicate that peers networked with a wide range of people in positions of power and authority for example they met the district superintendent of police to request that police stop arbitrary arrests and the district magistrate to avail social entitlements for fsws peer workers facilitated meetings for the fsws with the district legal aid authority to learn about their rights they engaged regularly with district health officials to avail free condoms and facilitate access to hiv testing for cbo members and met the elected local government representative several times to register their opposition to the local governments proposed relocation of brothels to an outlying area these networking efforts revealed the interventions assumptions of sources of hiv risk and positioned peer workers and their cbo as a force for authority figures to engage with this point is illustrated through the following report of a peer worker informing her peers about her interaction with the states home minister and the director general of police when the minister was arguing with me that the government will make a provision for rehabilitation we told him that sex work is continuing from many years and many people are doing this business how many people can the police arrest or rehabilitate i also said that if a police officer beats a sex worker instead of simply arresting her how can the sex worker later continue sex work … police does not have any right to beat sex workers while listening to the arguments the home minister ordered the police officer to stop arresting women who were found carrying condoms and also to stop beating sex workers at the time of arrest this example of networking illustrates the power of a peer worker supported by the cbo to initiate structural change within the government the ti intervention approach still monitored crisis indicators however fsws reported no instances of police violence the 24houraday crisis response system supported by the intervention was replaced by a cadre of cbo members who were trained and paid to work in crisis resolution furthermore the ti approach advocated use of public resources and fsws were encouraged to approach the district legal aid authority for crisis resolution one outcome of these new arrangements was that instead of collectively working on crisis resolution the data indicate that fsws settled crises individually the goal of the transition to have all hiv prevention interventions for fsws managed by cbos and not ngos led to various conflicts power struggles ensued between ngo staff and cbo leaders that managed hiv prevention interventions a study researcher recorded her discussion with an intervention manager who said that the staff did not respect or obey the cbo president because they said she is from that community and they dont pay much attention to her word this and other instances of the eroding power and authority of cbo presidents suggest that in the clsi approach although there were instances of power struggles among cbo members peer workers and intervention staff the focus of all was to reduce stigma and increase the power of sex workers visàvis external stakeholders in contrast in the ti approach the key power struggle reported at all sites with varying intensity was between the fsw community on the one hand and intervention staff on the other hand links between community mobilising and hiv prevention goals based on an understanding that fsws needed to continually engage in collective actions to reduce their risk of hiv the clsi approach institutionalised forums where peer workers linked the interventions community mobilising activities with those of the cbo we contend that this bridging by peers reinforced the community mobilisation goals of both intervention and cbos in contrast ti and cbo activities were delinked and the ti offered peer workers few social spaces where they could meet fsws furthermore in the clsi phase the interventions hiv prevention and fsw mobilisation activities were functionally separated yet linked through the activities of peer workers besides providing hiv prevention services peer workers also worked to form cbos which the intervention described as an operational strategy for social mobilisation of sex workers peer workers regularly met fsws in cbos to discuss and strategise about how to collectively address their concerns interviews with peer workers three years into the clsi showed that they understood their work as related to both hiv prevention and community mobilisation the following excerpt from an interview summary illustrates a peer workers links with the intervention and the cbo as peer worker the respondent gives condoms to sex workers brings them to the clinic tells them about hivaids … and cautions them to always use condoms she also attends meetings of the cbo leadership group to discuss problems and conveys decisions taken in these meetings … to the local cbo also if any sex worker faces any emergency situation it is her responsibility to inform the crisis response team integration of hiv prevention and community mobilisation was also reflected in the interventions monthly staff meetings which routinely reviewed cbo activities such as management of safe spaces for fsws and formation of a clinic management committee under the oversight of the cbo the clsi had various platforms where peer workers could meet fsws and plan their work for social change peers met fsws in their local areas at weekly solicitationsite group meetings and monthly cbo meetings they mobilised fsws to participate in events organised jointly by the intervention and the cbo to mark international womens day international sex workers day world aids day and international workers day peer workers had a dedicated monthly meeting alongside intervention staff peer workers were members of various specialised committees that met regularly to work on tasks such as procuring condoms from government running static and mobile clinics and managing the 24hour crisis response system these forums were designed purposefully to engender a sense of community among peer workers in the ti phase the functional and organisational separation of the cbo and hiv prevention was pronounced but not absolute the interventions achievement indicators focused on what staff referred to as the 4cs condoms clinics crisis and cbo however because peer workers were hired monitored by and accountable to only the intervention which now had a decidedly diseaseprevention focus their work on crises and building cbos was mainly for the instrumental potential to affect increased uptake of clinic services and condoms field notes indicated that in the ti phase peer workers from all sites reported very few crisis cases all of which were related to intimate partner violence peer workers told researchers that the few fsws who spoke of police harassment said they solved the matter privately they did not seek peer or cbo mediation as was the case in the clsi phase at peer worker and intervention staff meetings the primary information sought was the numbers of fsws registered at the cbos which then became the benchmark against which clinic utilisation and condom distribution were gauged during this phase there were fewer structured opportunities for peer workers to meet amongst themselves and with fsws in part this was a reflection of the separation of the intervention and cbo with reduced and interrupted funds flowing to the intervention apart from annual general body meetings of the cbo there were fewer reports of large gatherings of fsws although on paper specialised committees to coordinate intervention activities offered a forum where cbo leaders interfaced with peer workers and intervention staff the evidence indicated that not all committees had peer workers as members and these committees met infrequently fewer occasions to meet translated into fewer occasions for peer workers to reinforce a sense of community among fsws speaking to a researcher about this situation one peer worker observed after the takeover fsws who are not cbo members lost the linkages with the cbo … cbo members were not getting any information from cbo for any meeting or event in the ti approach cbos were tasked with mobilising fsws for activities other than hiv prevention cbos created and filled new positions at the cbo to do the work previously done by peer workers an informal norm of one personone position which precluded peer workers from taking on additional positions in cbos was enforced to develop a pool of leaders within the fsw community consequently some peer workers decreased their participation in cbo activities for example peer workers at one intervention site did not attend a local cbos annual general body meeting because they reported it was not a part of their work without large gatherings and frequent local group meetingsoccasions to recruit new fsws to the intervention and reinforce a sense of community among fswspeer workers reported difficulty in mobilising fsws to use services at government clinics and persuade fsws to attend cbo meetings for instance when a supervisor admonished peer workers for not bringing the targeted numbers of fsws to a cbo meeting they replied these words highlight that not only did fsws refuse to associate with cbos they perceived to not be working for their concerns but also that peer workers too were at a loss to explain the relevance of cbos to potential members it must be noted that it was possibly the success of the clsi that had brought fsws to the point where they confidently stated that they could independently access clinic services and condoms however these data highlight that peer workers of a tifocused intervention could not mobilise fsws as easily as their peers in a clsifocused intervention interventions use of peer worker inputs the clsi approach remained relevant to fsws through a continuous feedback loop among the fsws peer workers and intervention managers indeed beyond serving as educators peer workers were responsible for presenting fsw concerns to intervention staff one example of this was the way peer workers routed fsw feedback to the intervention which then revised clinic timings and procedures so that fsws use of services would not be compromised the project manager emphasised continually that it was the peer workers task to identify barriers that prevented fsws from accessing treatment and she attributed the high numbers of women accessing clinic services to the community mobilising efforts of the peer workers and cbo formation she said clinic service would be effective if peer workers are totally involved in the programme addressing these issues and the community mobilization would be high we find collectivization is a motivator to bring more fsws to the clinic later using peer worker inputs that identified outlying areas where fsws needed clinical services the intervention introduced mobile clinics to those areas similarly when peer workers reported at a cbo leadership group meeting that not all peer workers distributed the condoms they procured the intervention and cbo leaders discussed solutions although these solutions were not always successful the attention given to peer worker inputs by intervention staff indicates their value in providing relevant information for fsw programming in the ti field notes indicated that peer workers reported they could not meet their targets sometimes for several months because of nonavailability of testing kits or personnel at government hospitals or because fsws in their area had migrated out in these cases intervention staff merely encouraged peer workers to meet targets by motivating other fsws to attend field notes from the three sites indicated that peer workers repeatedly informed intervention managers and cbo leaders that their work was made tougher because fsws were not interested in clinic services only without other concerns being addressed a peer worker reported at a weekly meeting more than 10 times i do the visits for mobilizing community to attend meetings medical camps but all in vain none of the members show interest to get clinic services or attend the meetings however neither the intervention nor the cbos acted on this information to affect positive changes in their services or activities discussion the ethnographic material comparing the function of peer workers between a clsifocused approach and more traditional tifocused approach to hiv prevention intervention reveals clear differences between the two strategies we have shown that in the clsi approach the everyday work of peer workers went beyond just outreach and providing hiv information and prevention services to also helping fsws develop a sense of collective identity and power address police violence and economic vulnerabilities and access social entitlements the integration of the peer workers hiv prevention work with that of the cbos mandate of fsw collectivization mutually strengthened both goals in contrast peer workers in the ti approach had a narrow remit such that their work was effectively downgraded to outreach for sti prevention increasing fsw uptake of clinic services and condoms and enrolling new members in the cbo with a sharper separation between the cbo and intervention in the ti approach and limited spaces for peer workers to operate outside the clinic and condom distribution framework peer workers remained instruments of programme implementation efficiency and reaching preset targets rather than agents of social change differences in the work of peer workers in a clsiand a tifocused approach reflect different assumptions of the sources of hiv risk and the role of peer workers to address them the clsi approach recognises that the sources of hiv risk lie in structural conditions and prevention efforts need to attend to fundamental socio political and economic complexities operating at the local sites peer workers work as social change agents in the clsi approach at rajahmundry was based on the recognition that … powerlessness at the community or group level and the economic and social conditions inherent to the lack of power are major risk factors for poor health this perspective offered a wide scope for fsw participation individually peer workers became agents and collectively cbos became partners in the interventions social change agenda in contrast the ti approach viewed the sources of hiv risk primarily in individual behaviours accordingly it used the strategy of peer education based on the assumption that with appropriate information provided by trusted leaders and accessible preventive services the strong influence of peer pressure to adopt safe sex norms would be an effective mode of hiv prevention the radical dimensions of participatory empowerment and action found in the clsi approach were absent in the ti approach although both approaches leveraged peer workers insider status to reach fsws and address their risks only in the ti approach peer workers were involved functionally and instrumentally to enlist fsws into the intervention programmes secure their compliance and to make projects run more efficiently by involving them in delegated responsibilities community mobilising continued to exist as an important stated aspect of peer workers work in the clsi and ti phases yet in practice the change in its form intent and the extent to which peer workers engaged in community mobilisation reflected the importance of this tactic in each approach jana argues that community mobilisation is a political process which raises different types of challenges within and outside an interventions structure and which takes skill and commitment to implement the clsi and ti approaches used the language of community mobilisation in the expectation that the process would build cbos that would own operate and sustain hiv programming yet each approach differed on its commitment to engender community mobilisation in the clsi approach mobilisation was part of a freirian type of empowerment education process through which fsws were made aware of their shared problems and potential power to collectively address them the clsi approach supported peer workers community mobilisation efforts by creating organisational spaces where peer workers participated in planning decisionmaking implementing and monitoring intervention activities in the ti approach with a sharper separation of cbo and intervention and a narrower remit of peer workers activities the extent of peer workers use of community mobilisation decreased to be used only instrumentally in implementing programmes and reaching targets limitations this paper has several limitations the research strategies used for the clsi phase and for the ti phase are different clsi phase data are only from one site while the ti phase data come from three sites while this may not pose a problem for comparative ethnographic analysis caution must be exercised in generalising these findings to other crosssite or crossmodel comparisons conclusions implications for hiv prevention we have shown that the scope of work of the peer workers changed when the intervention transitioned from avahan to the government this suggests that despite maintaining the language of community mobilisation the ti no longer reflects the same underlying assumptions about the sources of hiv risk and hence no longer represents a community mobilisation intervention these findings have implications for hiv prevention programming having peer workers and a community mobilisation strategy in and of itself may not be enough for fsws to access hiv prevention services two other significant conditions appear to matter as well one condition is the underlying assumptions about the sources of hiv risk and the programmatic approach to address these risks where both peer workers and community mobilisation are key elements hiv prevention interventions may be less effective if structural sources of hiv risk are not identified and addressed and targets are focused solely on individuallevel changes in hiv risk behaviours the clsi model reflected the view that the risk of hiv was a result of power inequalities that constrained fsws ability to engage in safer sex practices peer workers mobilisation of fsws to demand changes in contexts that promote risk was a means of challenging these power inequalities interventions that addressed fsws vulnerabilities such as policing violence and lack of social entitlements and collective solidarity may raise awareness of the intervention among fsws who are vulnerable and powerless it is expected that this awareness may then translate into improved utilisation of the interventions hiv prevention services we found that interventions that did not appear to address fsws stated concerns did not appear to influence their utilisation of hiv prevention services moreover as fsws powerlessness is related to economic vulnerability and limited control over work conditions in sex work interventions that collectively empower fsws to address these concerns may reduce the hivrelated risk behaviours of fsws a second condition that is important to consider is the modes of participation available to peer workers and the communities they are tasked to mobilise in the intervention the clsi approach showed that peer workers community mobilisation and collectivization work hold the potential for redressing power imbalances in the ti approach community mobilisation was diluted of its transformative dimensions and used instrumentally only to lend legitimacy and bring efficiency to the work of interventions and its peer workers when the two approaches are compared evidence indicates that a clsi approach offers better outcomes for hiv prevention than does a ti approach this difference is attributed not only to changing the social and environmental context in which an intervention is situated but also to strengthening fsws perceived sense of power and building fsws capacity to bring about changes addressing power and powerlessness in hiv prevention interventions can best be done by peer workers whose work goes beyond education and clinic referrals to mobilising their peers through collective action and addressing the social and economic complexities that put them at risk of disease

we utilised a comparative ethnographic approach to study the implementation of a community mobilisation intervention addressing hiv risk among female sex workers fsws in india as implemented first by an nongovernmental organisation and after oversight of the intervention was transitioned to the government we demonstrate that the work of peer outreach workers changed from social change agents within a communityled structural intervention clsi to peer educators within a targeted intervention ti in the clsi approach built on the assumption that fsw risk for hiv is rooted in power inequality and structural vulnerability peer outreach workers mobilised their peers through communitybased organisations to address underlying conditions of inequality and vulnerability in contrast the ti approach which views fsw risk as a function of limited knowledge and barriers to services addressed peers access to information and health services analysis of changes in the function of peer outreach workers reveals critical differences of which we discuss four assumptions about conditions that produce hiv risk degree of emphasis placed on collective mobilising and building collective power extent to which community mobilisation and hiv prevention goals are linked and the interventions use of peer input we discuss the implications of these findings for hiv prevention programming

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introduction a persons identity values and stances are often reflected in the linguistic choices one makes this is why when language models are trained on large text corpora they not only learn to understand language but also pick up on a variety of societal and cultural biases while biases picked up by the plms have a potential to cause harm when used in a downstream application they may also serve as tools which provide insights into understanding cultural phenomena further while studying ways of surfacing and mitigating potentially harmful biases is an active area of research cultural biases and values picked up by plms remain understudied here we investigate cultural values and differences among them picked up by plms through their pretraining on web text in a wide range of social science research fields values are a crucial tool for understanding crosscultural differences as defined by rokeach values are the core conceptions of the desirable within every individual and society ie the foundation for the beliefs guiding a persons actions and on a society level the base for the guiding principles we would like to highlight the difference we make between values and morals the former as conceptualised in this work is concerned with fundamental beliefs an individual or a group holds towards sociocultural topics whereas the latter entails making a judgement towards individual or collective right or wrong for a discussion around the intersection of morality and plms we point the reader to talat et al in this paper we base our understanding of values across cultures on two studies hofstede which defines 6 dimensions to describe crosscultural differences in values and the world values survey both surveys provide numerical value scores for several categories on a population level across different countries and regions and are widely used to understand crosscultural differences in values plms are trained on large amounts of text from the web and have shown to pick up on semantic syntactical factual and other forms of knowledge which allow them to perform well across several natural language processing tasks since multilingual plms are trained on text in many languages they have the potential to pick up cultural values through word associations expressed in those languages which are embedded in the pretraining texts we therefore measure whether cultural values embedded in multilingual plms are correlated with the ones provided by the surveys in wikipedia which is one of the primary sources of training data for multilingual plms crosscultural differences have been established and analysed by hara et al based on hofstedes theory in this paper we explore the novel research question of whether plms capture cultural differences in terms of values across different language models we probe plms using questions from the values surveys of both hofstedes cultural dimensions theory and the world values survey we reformulate the survey questions to probes and extract the answers to evaluate whether language models can capture cultural differences based on their training data we focus on 13 languages each of which is primarily geographically restricted to one country or region to compare the results of the language models to the values surveys the overall experimental setting for the paper is outlined in figure 1 our work makes the following contributions 1 related work expression and norms analysis of expression of identity and attitudes through language and its change has a long history in sociolinguistics more recently studies have used nlp to computationally analyse this change on social media data and link it to external factors like socioeconomic status and demographics this has also been done to analyse broader societal trends like temporal change in attitudes towards sexuality and gender bias further there has been work on creating resources to analyse social norms and commonsense reasoning around them hoover et al roy et al present work on extracting moral sentiment embedded in language using the moral foundation theory to diversify visually grounded reasoning across different cultures liu 1 the code and data used for our experiments can be found here et al introduce a multimodal multilingual dataset while there has been work on investigating and embedding social and moral norms understanding values and their variation in a crosscultural context remains understudied in the literature kiesel et al provide a taxonomy of 54 values based on schwartz et al and provide a dataset and baselines for automatic value classification within the context of argument mining the closest setup to ours would be one adopted by johnson et al they qualitatively assess the text generated by gpt3 an autoregressive language model by prompting it with english texts with a clear embedded value they find that the embedded values in the generated texts were altered to be more in line with dominant values of us citizens possibly due to its training data our setup instead quantitatively measures whether crosscultural differences in these values are preserved in multilingual language models when fed with the language spoken predominantly by people belonging to that culture probing probing has been extensively used as tool to study a variety of knowledge and biases picked up by plms this can be syntactic semantic numerical relational or factual knowledge picked up by plms probes can be created on both at the word or sentence level following work on studying gender bias in word embeddings a number of studies have built on it to similarly probe for social biases embedded in plms this can be done using clozestyle probing for measuring at an intrasentence level or using pseduolog likelihood based scoring there are downsides to both approaches the former potentially introduces unintended bias based on the tokens in the input probe while the latter assumes that all masked tokens are statistically independent we choose the former since the probes in our case are carefully worded by social scientists with the explicit aim to extract bias towards a certain set of values to the best of our knowledge there is no existing value probing in this paper we explore how plms capture differences in values across cultures and whether those differences reflect the ones found in values across cultures at large while the wvs was developed in the field of political science both studies have since been widely used across fields hofstedes cultural dimensions theory hofstede started his surveys of crosscultural differences in values in 1980 this first survey included 116000 participants from 40 countries working with ibm and created 4 cultural dimensions which were subsequently extended to 6 cultural dimensions that are also used in this paper these 6 dimensions are power distance individualism uncertainity avoidance masculinity longterm orientation indulgence the full survey contains 24 questions each dimension is calculated using a formula defined by hofstede using 4 of the questions in the survey see appendix f hofstede shows the influence that culture has on values by defining distinctly different numerical values in those 6 dimensions for the cultures observed while critics of hofstedes cultural dimensions theory point out among others the simplicity of the approach of mapping cultures to countries and question the timeliness of the approach we exclude categories and for the experiments in this study this was done due to the nature of questions asked in these categories for which it was not straightforward to design mask probes without loss of information inglehart who established wvs further defines the inglehartwelzel cultural map which processes the surveys and defines two dimensions 2 in relation to each other traditional versus secularrational values and survival versus selfexpression values and summarise values for countries on a scatter plot describing these dimensions in the following we only use the previously mentioned 11 categories and leave an analysis based on the inglehartwelzel cultural map for future work probe generation in order to make the surveys compatible with language models we reformulate the survey questions to clozestyle question probes that we can then perform masked language modelling inference on since this is the task plms were trained on we argue it is a suitable methodology to measure embedded cultural biases in these models hofstedes cultural dimensions based on the english survey questions the questions in the survey are manually reformulated to question probes this is done analogously to iterative categorisation in which a set of possible labels corresponding to either end of the response options available in the survey are defined which are the words the language models are probed for the sentences are then reformulated to probes and the labels masked those labels are based on the answers of the original survey for instance the original question like have sufficient time for personal or home life with answer options consisting of different degrees of importance the probe is reformulated to having sufficient time for personal or home life is mask where mask should be replaced by important or unimportant qps w i y i y i where w i is the masked probe and y i and y i are the set of labels there are a total of 24 questions with repeating labels world values survey analogous to the probes created from the hofstede survey we create probes from the english questionnaire of the wvs as there are more questions than for hofstede there are also a larger number of labels to replace and a higher variety of question types multilingual probes to probe across several languages we follow a semiautomatic methodology for translating the created probes in english to the target language we use a translation api 3 that covers all target languages we translate each qp from english into the target language with the mask token replaced by the label words y i y i in order to maintain grammatical structure and aid the translation api one challenge of crosscultural research is information loss when translating survey questions therefore we opted for this approach rather than reformulating the translated survey questions by hofstede however we would like to highlight the shortcomings of machine translation which have poor performance on low resource languages and has the potential to introduce additional biases for the purpose of these experiments however since the question probes are relatively simple sentences we found the machine translations to be of high quality we conducted an evaluation of our machine translated probes the details for which can be found in the appendix b the target labels y i y i for each qp are then translated individually as single words followed by lowercased string matching to check if the translated label can be found and replaced in the translated probe if the target label cannot be found directly in the translated probe due to differences in word choice we use a crosslingual word aligner to align the english probe and its translated version with this approach we identify the label word to be replaced with the mask token if both approaches yield no result the token is manually replaced in the target sentence based on the authors language understanding and using online translators language selection in total we investigate 13 languages mapped to one country each as outlined in table 1 according to criteria further detailed below one of the limitations of this onetoone mapping is that the languages are spoken in wider regions and not specifically in one country this allows for the closest match to the values theories we work with which operate on a country level the definition of culture by country has been criticised by eg nasif et al we select the languages as follows we first include the countries covered in both the surveys of wvs and hofstede we limit to languages which are official languages of the countries observed in the studies of both wvs and hofstede we further select languages for which the distribution of speakers is primarily localized to a country or relatively narrow geographical region to ensure the language models will be able to have sufficient amount of training data from the set of languages only those are selected which have at least 10000 articles on wikipedia 6 methodology models we conduct the probing experiments on three widely used multilingual plms the multilingual uncased version of bert base the 100 language mlm version of xlm and the base version of xlmroberta it shows strong multilingual performance across a range of benchmarks and is commonly used for extracting multilingual sentence encodings mask probing for each model m we run inference on the created clozestyle question probes using an mlm head producing the log probabilities for the mask tokens in the qps over the entire vocabulary v of the respective model logp m ∈ r v where t is the position of the mask token in the text w i ∈ qp and θ m are the parameters of the corresponding language model m since the survey respondents have to answer the questions with a choice between a range of values for instance 110 with 1 representing democratic and 10 representing effective in order to replicate a similar setting with plms we subtract the predicted logit for the response label with the highest score w i with the predicted logit for the lowest score w i this normalises the predicted logits for the responses on opposing ends of the survey question and is then used as a score for that question logp m logp m logp m finally in order to collapse the world values survey responses per category within which many questions have different scales we normalize the aggregate survey responses per the corresponding question scale so that y ic ∈ 0 1 c ∈ c we then take the mean of the responses across all the questions of the category to arrive at the aggregated score of the category for each country y i 1 c c∈c y ic ∈ 0 1 evaluation we calculate spearmans ρ a rank correlation coefficient between the values predicted by the language models and values calculated through the surveys ρ y i for the world values survey we do this per question as well as per category for hofstede we limit this calculation to value level correlations due to lack of access to individual or aggregate survey response data per question 4 we further calculate correlations per country spearmans ρ works on relative 4 we calculate the scores for the values based on the formula provided at eduorkelmkelmpubvsm2013manualpdf see appendix f predicted ranks to each variable ignoring the individual predicted values our choice of using a rank correlation was motivated by the fact that we are working with population level aggregate responses and our aim of assessing whether language models pick up on relative differences in values across cultures rather than on exact values results rq1 model predictions we show the predicted scores for the xlmr model in figure 2 as is clear from the figure there are substantial differences in the predicted scores for the cultural dimensions across cultures on average scores for power distance are high whereas ones for masculinity and indulgence are relatively low the predicted logits suggest bias towards greece and south korea as places with high power distance pakistan germany as more masculine indulgence has the lowest scores across all values with only phillippines and malaysia having positive values indicating high restraint in these cultures according to the model predictions to understand whether lms can preserve crosscultural differences in values we plot the results of the probing for hofstedes and wvs survey in figures 3 and4 respectively as is visible in these plots there is a variety in the values ie the models seem to place different importance on different values across cultures displaying crossfigure 3 scatter plots with quartiles of predicted value scores on hofstedes survey questions for each of the three models figure 4 scatter plots with quartiles of predicted value scores on wvs questions for each of the three models cultural differences in the values we quantify these differences among the prediction scores by testing for statistical significance between the models predictions by culture seeing how they capture crosscultural differences for xlmrs predictions for the wvs 4231 of the country pairs have a statistically significant difference meaning the model preserves crosscultural differences for the other two models the share of significantly different country pairs are 5128 and 4615 for mbert and xlm respectively for xlmrs predictions of hofstedes survey only 1026 of cultures have p 005 for the other two models the share of significantly different country pairs are none and 641 for mbert and xlm respectively we attribute these low percentages to the fact that we conduct the test over the six value dimensions only while it is on over 200 questions for wvs rq2 model agreement to further study whether scores across values and categories are consistent across the three models we check for correlation between the predicted scores between the three models and outline them in tables 2 and3 we can see that predictions are inconsistent across the models indicating differences in the embedded crosscultural values mbert and xlm share the same architecture and are both trained on wikipedia yet the correlations across values are low indicating the large effect that relatively minor changes to the model training can have on the cultural values picked up by the model rq3 alignment with surveys finally we investigate whether the models predictions for the values questionnaire are consistent with existing values survey scores hofstede we outline the results of correlations between each of the models predictions for mask probing per value in table 4 we find no statistically significant alignment between the models predictions and survey value scores provided by hofstede but given the low sample size this is to be expected we find weak correlations among some of the values between the models predicted scores and the values survey suggesting the disparity in cultural values outlined by hofstede and the ones picked up by plms wvs table 5 similarly shows the correlations between the models predicted scores and the world values survey scores per category here too we find no statistically significant correlation between the predicted and the survey scores outlining the difference in values picked up by the language models and those quantified in the surveys we also check for per country correlations between the predicted scores and data from both values surveys these are shown in tables 11 and12 in the appendix discussion our experiments show that there are sizable differences in the cultural values picked up by the different multilingual models which are widely used for a number of language tasks even when they are trained on data from the same source this is in line with previous results and hints at the sensitivity of model design training choices and their downstream effect on model biases while the values picked up by the models vary across cultures the bias in the models is not in line with values outlined in existing large scale values surveys this is an unexpected result since plms are known to pick up on biases present in language data that they are trained on further values are known to be expressed in language hence language models should pick up on and reflect cultural differences in values expressed in different languages based on their training text a lack of such reflection points to possible shortcomings in representation learning when it comes to multilingual language models there could be a number of reasons for this one possible reason is the lack of diversity in multilingual training data wikipedia articles in different languages are written by a small subset of editors that are not representative of the populations in those countries further large scale corpora like commoncrawl overrepresent the voices of people with access to the internet which in turn overrepresents the values of people from those regions such a bias being present in gpt3 was explored by johnson et al who show that lms trained on web text end up reflecting the biases of majority populations other work also shows that pretraining text contains substantial amounts of toxic and undesirable content even after filtering this highlights the need for including more diverse and carefully curated sources of data which are culturally sensitive and representative in order for the models to better reflect the cultural values of those populations joseph et al suggest that people express themselves differently online on twitter compared to survey responses this is another potential reason for this misalignment plms are used for a variety of different nlp tasks in different countries and hence to accommodate the usage of people from diverse backgrounds and cultures it is not just important to have linguistic and typological diversity in training data but also cultural diversity having such a form of cultural knowledge is desirable for a number of realworld tasks including qa systems dialogue systems information retrieval further a lack of such faithful representation could lead to unintended consequences during the deployment of such models such as models imposing a set form of normative ethics over a diverse population that may not subscribe to it this could also lead to models not being culturally sensitive and embedding harmful stereotypes recently work has been done on trying to align models with human values while this may seem like a good idea at a first glance also in light of the arguments presented above some cultural values are harmful to portions of society eg high levels of masculinity which is connected to misogynistic language and perpetuating gender biases thus when working with cultural values an auditing system with these value systems in mind and one that takes into account the downstream use case should be employed conclusion in this study we propose a methodology for probing of cultural values embedded in multilingual pretrained language models and assessing differences among them we measure alignment of these values amongst the models and with existing values surveys we find that plms capture marked differences in values between cultures though these in turn are only weakly correlated with values surveys alongside training data we discuss the impact training and modelling choices can have on cultural bias picked up by the models we further discuss the importance of this alignment when developing models in a crosscultural context and offer suggestions for more inclusive ways of diversifying training data to incorporate these values ethical considerations the ethical considerations for our work mostly relate to the limitations there are a variety of unintended implications of equating a language and a country such as misrepresentation of communities and disregarding minority and diaspora communities however we believe it is the closest approximation possible when comparing the surveys used in this work and lms further the surveys have been criticised particularly hofstedes cultural dimensions theory has been deemed too simplistic this could lead also to simplistic assumptions when probing an lm we address these problems by including the wvs another widely used survey in our study due to these limitations we believe that further studies and applications of our approach should be done with these limitations in mind particularly the simplification of cultural representation by both our approach as well as the original surveys might impact communities negatively such misrepresentation can have a disproportionate impact and exacerbate the marginalisation of minority communities or subcultures a limitations there are several limitations of our approach in trying to assess cultural diversity and alignment of the values picked up by plms while our methodology of probing models using cloze style questions gives us some insight into token level biases picked up by the language models it is limited in its approach to only show static and extrinsic biases at inference time using output probabilities there are intrinsic measures for quantifying bias but those do not always correlate with extrinsic measures in order to make the experimental setting more robust and clearly demonstrate signs of embedded cultural bias we performed experiments with an extended set of synonyms for each label word however this turned out to be nontrivial for a number of reasons first replacing synonyms in place of original words rarely results in grammatical sentences second it is not always possible to find multiple synonyms of words in the same sense as the label words across the languages used in our study third even when synonyms do exist they are often multiword expressions which makes them incompatible with our experimental setting where a single word needs to be masked as discussed earlier a major limitation that comes with quantifying cultural values is the mapping of countries to cultures and in our case also to languages since this is an imperfect mapping it is a difficult task to accurately quantify and assess cultural bias and values embedded in the models we partially addressed this by restricting our study to languages which are mostly geographically restricted to one country this is a limitation faced by crosscultural research in general where countries are often used as surrogates for cultures finally surveys and aggregate responses are also imperfect tools to evaluate and quantify cultural disparity though the best ones currently in use they are tasked with collapsing individual values into a set of questions individuals answering those questions from different backgrounds may perceive the questions differently further there are several confounding factors affecting the survey responses and problems relating to seeing populations as a monolithic homogeneous whole while these limitations pose important questions around how one should be careful in interpreting these values we believe our study makes important contributions and provides a first step in assessing alignment between plms and cultural values which we argue is necessary for models to faithfully work in a crosscultural context b translation quality to assess the quality of translated probes we conduct human evaluations of a sample of the output of the machine translator we randomly select 3 probe questions from the hofstede values survey and 23 probe questions from the world values survey representing 10 of the total probes we then provide the original probe questions in english as well as their translations to annotators and assess the following two characteristics of the translations • grammaticality describes the correctness of the sentence standing alone independent of the english sentence in terms of obeying grammatical rules • meaning describes how adequate the translation is for further reuse we specifically want to know here how correct the sentence is in relation to the english sentence this could be also understood as the overall quality of the translation for each of the 26 probe questions we ask the annotators to rate the sentence on the above listed characteristics across a 15 likert scale all annotators had at least a university level education working proficiency of english and were native speakers of the corresponding languages we perform this annotation for 6 out of the 13 languages due to resource constraints we provide the averaged scores for both the characteristics for each language in table 6 the annotators on average across languages rate the meaning characteristic of the machine translated probes to be 473 this indicates the high degree to which the translations preserve the meaning of the sentences from the english probes the grammaticality of the probes on average was rated to be 464 while lower than the value for the preserved meaning of the english sentence the sentences were found to have very good grammar as well the very high scores across the meaning characteristic of the translations suggest that for most of the probes the translations were of high quality c models and compute all models were run in python using pytorch ers library when speaking about xlmr mbert xlm we refer to the models with the names xlmrobertabase bertbasemultilingualuncased xlmmlm1001280 respectively since only inference was performed for probing the models the experiments were run on a single nvidia titan rtx gpu for less than 1 hour d ablations d1 label logit subtraction to eliminate the possibility of lack of correlation due to subtraction of logit for label token with the lower response score in the survey question from the one with higher response score we calculate correlations with just the high response label token y i we report our results for hofstede in table 7 and wvs in table 8 similarly we calculate value correlations for just the low response label and report them in table 10 e example probes in table 13 we provide a sample of the question probes in english that are then translated to the different languages outlined in section 5 f hofstede value calculation we calculate the value results for the probes based on hofstede by using the formulas used in the original survey 5 the numbers following m represent the index of the survey questions m stands for mean representing the mean survey question response for the answer to that question c is a constant that does not influence the comparison between countries power distance defined as the extent to which the less powerful members of organizations and institutions accept and expect that power is distributed unequally individualism measures the degree to which people in a society are integrated into groups uncertainity avoidance measures the extent to which a culture programs its members to feel either uncomfortable or comfortable in unstructured situations

language embeds information about social cultural and political values people hold prior work has explored potentially harmful social biases encoded in pretrained language models plms however there has been no systematic study investigating how values embedded in these models vary across cultures in this paper we introduce probes to study which crosscultural values are embedded in these models and whether they align with existing theories and crosscultural values surveys we find that plms capture differences in values across cultures but those only weakly align with established values surveys we discuss implications of using misaligned models in crosscultural settings as well as ways of aligning plms with values surveys

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introduction the global population of people living with dementia is estimated at 468 million and expected to double every twenty years 1 greater demands for holistic person centred care is required now and for the future 2 dementia is a term for a cluster of symptoms that degenerates the cells in the brain leading to impaired memory thinking problem solving and language it is a complex condition because each presentation is unique to the person and their needs change overtime internationally innovations in person centred care provision drivers for earlier diagnosis environmental design and housing have created opportunities to support people live with autonomy on their dementia journey equally the voice of people living with dementia has strengthened amplifying their needs and gaps in research 3 technology has been proclaimed as a solution to support current care provision and an abundance of innovation has emerged over the last twenty years 45 the complexity of this research field means it can often be difficult to identify the useful solutions for people living with dementia the purpose of this research is to explore the experiences of people living with dementia and their caregivers as they live in technologyenriched supported living environments within the united kingdom government industry and research investment has been considerable to drive innovation of technology to improve wellbeing independence and length of life 6 policies such as the challenge on dementia 2020 focused on improving care increasing research and raising public awareness in england equally european research funding schemes have sought to capitalise on technology advancement for public health the world health organisation global action plan on the public response to dementia specifically sets out that technology is a core principle in the provision of dementia care and advanced planning guidance from the national institute for health and care excellence sets out person centred care at the heart of dementia service provision 7 technology within dementia care needs to balance technology as a care approach and the personhood of those living with dementia 8 person centred practice has parallels with recent research in human computer interaction and technology design for and with people living with dementia 9 adopting a critical dementia lens to technology provision focuses on the unique experience of the dementia journey from a social constructionist point of view 10 this viewpoint considers technology as a tool for empowerment and recognises the unique needs sense of self and potential of people living with dementia 11 assistive technology or technology can be defined as a system or device that enables the person to complete a task they would not be able to do at all or with ease without it it is a very broad term particularly when it is applied to the various ways and devices that could be used to support people living with dementia it describes a vast spectrum of systems from standalone devices to complex ubiquitous smart home environments 12 assistive technologies can be classified as being used by the person living with dementia with the person living with dementia or on the person living with dementia 13 user activated technology refers to devices the person engages with such as a touch screen device call systems to seek help mobile phones and therapeutic interventions passive or pervasive technology are monitoring systems used on people such as sensors to detects motion pressure inactivity falls and temperature this technology does not require any active input from the user and sends signals to the caregiver when assistance is required localisation technologies are generally wearable like a pendant or bracelet and support locating a person if they get lost 14 automatic prompts and reminders like medication dispensers and electronic calendars can be useful solution to use with people living with dementia everyday technologies such as virtual assistance like amazons alexa can support orientation and the activation of devices such as lights and television equally the marketplace has a range of smart watches and smart phones assistive technology is more commonly used for safety as opposed to a device for wellbeing and leisure 15 in 2016 gibson and team reported 17 million telecare users and 171 different technology products 13 the wide spanning variation of devices and the limited voice of people living with dementia was a common theme reported in systematic literature reviews in this field 16 17 18 19 additionally a number of useful prototypes reported in research have not made it to the market place 20 the biggest barriers for assistive technology adoption are people living with dementia not wanting to use it 21 cost 21 access 22 and digital literacy 23 recent reviews indicated the need for robust research to support the adoption and use of solutions for everyday living 45 furthermore research is required to determine the benefits of customisable solutions to support people throughout their dementia journey 17 this has implications for clinical practical and care provision as it is difficult to determine the usefulness and userfriendliness of assistive devices and telecare for people living with dementia and their caregivers there are no guidelines on the provision of assistive technology in dementia care attila a randomised control trial found that assistive technology provision for people living with dementia ageing in place is not in line with best practice as the provision of technology often does not follow the recommendations made by assessors 15 further research is required as no psychological impact was found within the informal caregiver group when assistive technology and telecare was used to compliment care at home 24 the findings also indicated that assistive technology and telecare did not necessarily maintain ageing in place for longer 2 highlighting the importance of innovation in housing models living at home for as long as possible is enshrined in policy and supported by technology provision 1 where a person lives is intrinsically linked to their personhood and essential to support quality of life 25 therefore it is important to consider the environment along the continuum of care that is appropriate for a person to move into when community living is no longer a feasible option supported living provides an alternative housing model and incorporates dementia design principles and person centred practice into its ethos 26 different terms are used to describe this housing model such as extra care housing 27 assisted living 28 and small home like facilities 29 telecare and assistive devises are often used to support independence 30 and foster person centred care 31 the housing model offers domiciliary care according to need and informal caregivers are expected to maintain a caregiving role in collaboration with formal caregivers supported living aims to offer independence and autonomy as a community based housing model however a recent literature found this is not always achieved due to lack of resources 32 limited research has considered the potential of technology to support tenants independence and autonomy within this housing model 33 technology intervention can be an asset to the caregiving role 2 both informal and formal caregivers can benefit from the innovation 34 especially as caregiving changes during the transition from community to supported care environments 35 and throughout the dementia care pathway 36 equally research illustrates that caregivers play a key role in enabling active use of technology in the lives of people living with dementia 37 informal caregivers in the community are more likely to be using technologies in their everyday life and as a result have the digital literacy to incorporate assistive technologies into supporting care provision 38 gullslett and team 39 explore next of kin experiences of monitoring technology in residential setting and highlight the different needs information and expectations each caregiver will have in terms of the use of such devices the importance of collaborative practice was also highlighted as essential the challenges identified was providing informal caregivers with information that met their needs and digital literacy levels 39 assistive technology can support formal caregivers reduce the burden of care and uphold their duty to protect people from harm 40 the devices were found to support formal caregivers to react at speed when required and enable people living with dementia to live independently at their own pace 41 research has identified challenges such as alarm fatigue device maintenance and the lack of robust design to withstand the daily routines within a long term care setting 42 in addition the multiple dimensions of the environment as a workplace a home and a care provider present ethical issues 40 the concept of surveillance and workplace oversight can be a barrier to formal caregiver adoption 42 assistive technology did not appear to impact the decision to move into supported living settings however it was valued as a support system by informal caregivers post transition 43 the landscape of the care environment changed rapidly as a result of covid19 44 during the pandemic people living with dementia were at risk of social isolation during periods of restricted measures 45 and digital technologies provided potential for social connectedness particularly with families and friends outside of the care environment 46 covid19 created rapid change in the way technologies were used and exacerbated the gap between technology adopters and those with low digital literacy 11 in terms of care provision it was found that technology supported communication between formal and informal caregivers to support the emotional wellbeing of people living with dementia in long term care setting during the pandemic 47 even with wide spread innovation in this field there is limited research into technology design delivery and experiences in supported living environments 48 the role of technology for people living with dementia and other stakeholders became even more important during a global pandemic 1147 research highlights the extensive ethical debate around the use of monitoring technologies 4950 however little is known about the firsthand experiences of those living alongside technology that has the potential to be use with by and on them and their caregivers aims • to examine the experience of living in a technologyrich environment by people who have dementia that live in these settings • to explore stakeholders attitudes towards technology use in the housing scheme methods research design the purpose of the study was to capture indepth understanding of technology enriched support housing from the perspectives of three stakeholder groups the tenants living with dementia their informal caregivers and formal caregivers a qualitative study with older people as peer researchers was adopted peer researchers were recruited and trained to conduct the interviews with tenants living with dementia the focus of this paper is to report on the perspectives of technology from all stakeholder groups recruitment twelve housing schemes that were recorded as providing supported living for people living with dementia in a technology enriched environment were identified through a government department a technology enriched environment was where a range of telecare and assistive devices such as alarms sensors and monitors were embedded into the living environment to support care the housing schemes were registered as having technology as part of the care provision with government agencies and this was confirmed through a technology audit by the research team an information pack including consent forms and scheme participant information sheets were posted to the eligible housing schemes one scheme responded that provision was not for people living with dementia eleven housing schemes expressed interest a site visit to each housing scheme to identify if they met the inclusion criteria excluded one site due to the nature of care provided as it was not defined as supported living and a second site decide not to commit due to time site h was part of the project up until the tenants interviews when it became clear that people living with dementia were no longer living in the supported living section of the scheme the recruitment of tenants informal caregivers and formal caregivers were from the schemes that consented to their involvement in the project tenants were recruited by the scheme manager in partnership with the research team through purposeful sampling process consent was adopted and aligned to the approach used daily with the tenants scheme managers consulted with family members and tenants provided consent for themselves written consent was viewed as valid at the time the trusted staff member went through the participant information sheet to explain the study and obtain written consent on the day of the interview verbal consent was sought and visual cues were observed to ensure an ongoing fluid approach to consent was adopted recruitment for the survey was undertaken through the housing schemes after the onetoone interviews were completed informal caregivers and formal caregivers could complete an online version held on survey monkey or a hardcopy survey the links to the online survey were sent to the scheme manager to be distributed to both staff and family and friend caregivers the hardcopy of the survey was left at the entrance to the housing scheme for a sixweek period with a box to submit the survey after completion sample a total of eight schemes completed all aspects of the project twenty females and two males with a confirmed diagnosis of dementia participated in the interviews one female was under sixty and lived with her husband participants were not asked specific demographic information in line with recommendations set out for inclusive engagement with people living with dementia in qualitative research 5152 two interviews were excluded after it became clear the individuals were not living in an environment with technology to support their care informal caregivers completed n 20 surveys and formal caregivers completed n 31 table 1 inclusion and exclusion criteria data collection technology audit the technology audit tool was developed as an outcome from the systematic review undertaken in the project 33 due to the breadth of data to capture from the schemes and the complexity of terms for nonexpert users in this field it was decided to divide the audit into two parts the first part was a template for completion by a designated person to complete in their own time and email it back to the research team a followup phone call was then made to the designated person to discuss the outcome of audit form a and complete part b over the phone a total of eight schemes completed audit form a and four completed audit form b all data was included even if the second part of the audit was not completed tenants perceptions of technology semistructured interviews were undertaken with tenants facilitated by peer researchers peer researchers were seven older people with experience of caring for people with dementia that used their experiential knowledge to facilitate the interviews details of the peer researcher role and experience was set out in a separate paper 53 a total of twenty females and two males with a confirmed diagnosis of dementia participated in the interviews the interviews were held at a time and place decided by the tenant in collaboration with a staff member within the housing scheme each interview began in the same manner the first author of this paper and peer researcher were introduced to the participant by the member of staff in the location for the interview the staff member outlined the purpose of the interview and the tenant confirmed they were still happy to take part in a onetoone interview and consent to the use of a voice recorder the researcher then introduced the project and her and the role of the peer researcher once the voice recorder was switched on the peer researcher took the lead in the interview and asked questions based on the topic guide questions were focused on the general experience of living in a supported living environment and the technology within the environment the interview was guided by corte guidelines 52 the peer researcher aimed to build a rapport with the tenant and reflected on their own lived experience at times the first author kept a diary of the interviews to capture her own experiences and feelings and those of the peer researcher following a debrief informal and formal caregiver survey a cross sectional survey of formal and informal caregivers exploring the use of electronic assistive technology in supported living environments was developed for this project the items were generated through a systematic literature review 33 and interviews with informal caregivers 43 and formal caregivers 41 the survey included nine likert type data items and openended questions delivered as a selfadministered survey through an online platform and hard copy distributed within the housing scheme the development of the survey was first described in the final report 54 the likert type data items ranged from strongly disagree disagree neutral agree strongly agree no attempts were made to combine the responses into a scale to create a score statements were balanced accordingly so n 3 items were positive n 4 items were negative and n 2 were neither positive or negative the likert statements were the same in both ic and fc surveys to enable a comparison of their perceptions towards the use of technology and are presented in table 5 in the results section demographic questions and openended questions were set out at the beginning of the surveys open ended questions included are there any advantages to the use of technology to support your friend or relative please explain your answer do you these questions were asked as part of a larger interview and therefore not asked in the above sequence think tenants should have access to the internet does technology impact your caregiving role finally an explanation of the term technology was outlined at the beginning of the questionnaire to ensure each participant was aware of the meaning within the current project data analysis the data from the technology audit was extracted from the forms input into excel categorised and presented descriptively all survey responses were input into survey monkey and collated onto excel the responses from ic and fc were populated separately closed questions were analysed using descriptive statistics the openended questions were organised into themes and described descriptively finally the data from the likert statements were compiled according to the type of caregiver and presented in table format all recorded tenants interviews were transcribed verbatim and input into a qualitative data analysis computer software package each interviewee was given a pseudonym thematic analysis was used and started with the process of familiarisation as set out by braun and clarke 5556 the six phases for analysis familiarising yourself with dataset coding generating initial themes developing initial themes developing and reviewing themes refining defining and naming themes and writing up were followed deductive coding using both semantic and latent codes were generated by the first author during two rounds of coding the codes and the coded data were examined independently to generate patterns of meaning and themes the candidate themes were then discussed within the wider team a workshop was conducted with peer researchers to collaboratively interpret the data the peer researchers were asked to read the transcript of the interviews they completed and highlight the important components a group discussion generated and consolidated the themes further in advance of the group exploring the themes the research team had developed the similarities and differences were highlighted and themes were further developed the themes were checked against the entire dataset and named this approach enabled a process of peer validation and opportunities to reflect on the findings in the team including the peer researchers rigor was maintained throughout the analysis through journaling checking interpretations with peer researchers and maintaining one researcher through all data collection and analysis rich quotations are used with the intention of maintain the accuracy of the voice of participants results technology audit a total of eight schemes completed audit form a and four completed audit form b the earliest technology enriched scheme was opened in 2002 while the most recent was opened in 2014 four of the schemes emphasised the advantages of the technology in terms of the independence and security it provided the housing schemes highlighted the ethical use of technology with human rights privacy and dignity prioritised for tenants the use of the technology was personalised according to choice and the specific needs of tenants this nonrestrictive approach to technology use aimed to support the independence safety wellbeing and health of tenants the audit illustrated a heterogeneity of technologies within the housing schemes three out of the four schemes that responded to audit b stated that their technology systems were bespoke for their scheme the themes of safety and risk management resonated through the audits as did the need for personalised and personcentred approaches one facility pointed out the need to modernise the technology as it remained unchanged since its inception more than ten years ago however certain systems that would have been great now have since failed and not been replaced the technology in the scheme that is useful is the intercom system to our handsets however this is also starting to fail and will need replaced site e table 3 sets out the types of technology used within each of the housing schemes for example close circuit television was used in five settings and intercom systems in the tenants living space were used in seven settings this enabled tenants to speak with staff through a handset as well as staff received alerts from movement sensors and call requests in two housing schemes the intercom system supported the tenants to view the person ringing their door bell site i felt there is but its not used very often because it is confusing for tenants technology for example sensors on beds and chairs and fall detectors were reportedly used when a tenant needed to use these devices as opposed to every tenant in the housing scheme enuresiscontinence sensors were not reported wearable devices were available in most schemes however were only worn by tenants when a need was identified the sites that reported availability of certain wearable devices are outlined in table 4 one scheme stated wrist pendants are a choice made by tenants and their families but encouraged by the scheme in fig 1 the digital devices used in schemes by tenants were highlighted a mobile phone was commonly reported the other device available in site i was the snoezelen room tenants consented to the technology within the scheme during the orientation following taking up tenancy methods of seeking routine and emergency support from staff members were through the same approach via fixed wall buttons pull cords and wearable devices and invaluable in detecting a uti in addition the technology was usefully for nighttime monitoring tenants perceptions of technology the themes that derived from the analysis were attitudes and engagement with technology technology enhancing tenants sense of security seeking support and digital literacy and technology enabled connection attitudes and engagement with technology interviews revealed a mixture of attitudes towards the technology in the surrounding environment from not being aware to a vital aspect of independent living and the ability to connect with others participants described a range of devices during the interviews such pendant alarms pull cords buzzers intercom systems computers laptops tablets and mobile phones the types of devices ranged from personal electronic devices for social interaction to wearable devices to seek formal support communication systems and lowtech alerts systems like pull cords a key use of the devices mentioned was for seeking support from formal caregivers the lack of awareness about the technology in the surrounding environment was a major finding within the tenants interviews a total of eight participants had no knowledge of the technology at the time of the interview and were passive users of the pervasive technologies used on them peer researcher do you have any sort of system in the flat that you can use to call the staff celine no no i dont have anything like that peer researcher no wee emergency buttons celine no the findings were aligned to the nature of technology as pervasive and unobtrusive within the supported living environment when participants were asked about technologies and alarm systems they regularly spoke about testing the fire alarm in the scheme on the other hand two participants had significant knowledge of technology in their surrounding environment and of digital devices including the use of computers and tablets the decision to move into the housing scheme was based around the technology provision offered susan felt that the technology in the supported housing would provide a support system to remain independent safe particularly at nighttime and an active citizen for longer i didnt feel safe on my own environment so i was looking for somewhere to make me feel safe and secure susan twelve participants had varying degrees of basic knowledge around technologies primarily used to support their care many participants referenced the pull cord that was part of routine care provision as opposed to a unique system characterised by the telecare and monitoring technologies embedded in the environment these participants tended not to use technology beyond seeking caregiver support this required some active engagement with the devices in their surrounding environment technology enhancing tenants sense of security participants were living in an environment with pervasive technologies used to support care it was evident that overall within the technology enriched housing schemes tenants felt safe and maintained a sense of privacy more than anything you have an awful lot of privacy if you want your privacy you get it emma wearable devices were used by some tenants as part of their care plan the wearable devices were both acknowledge and unacknowledged while worn during the interview it was evident from the people who were aware and used the technology in their environment that it gave them a sense of security knowing there was immediate access to support when required the ability to request support from the privacy of their own space enabled independence and autonomy i feel comfortable because i know theres always somebody here if i need anything … i feel secure clare wearable devices also enabled community engagement and the ability to leave the housing scheme this further extends the freedoms of the tenants and provides a mechanism to access a level of support beyond the housing scheme bed monitoring sensors alerted formal caregivers when tenants got out of bed participants spoke about the comfort this provided particularly when they woke in the morning and it also gave peace of mind if nightwalking this enabled caregivers to be notified to check on the tenant or have an interaction through an intercom one participant spoke about how when she gets up staff would ask her how she was through the intercom they would speak through sometimes in the morning there is something here that alerts them its here below the bed …its a good thing because it makes you feel safe denise falls were reported frequently within the interviews and were often cited as the reason the tenant had transitioned into the housing scheme this created a level of apprehension around future falls and independent living technology was reported as reducing this apprehension it could be used in an emergency to seek out formal support and this gave reassurance to those who would need additional support thats what i have the cord for if i needed anything or if i fell im always very prone to falls but then i dont mind i dont mind falling now because if i fell or anything thats what that theres for i just pull that clare decision making for future care needs was possible and reported in this environment one participant spoke about her choices for using technology in the future as her dementia journey progresses she had discussed and given her consent to the scheme for the future use of sensors on her doors as she was particularly concerned about nighttime walking when asked if she felt the use of technology would have an impact on her privacy she responded i dont personally to be honest i think if it keeps you safe susan seeking support and digital literacy the way in which a person interacts with the technology in the surrounding environment was an important pattern in the data this theme reflected the tenants awareness of technology in their lived environment and their literacy to use the systems when they need to it was also reflected in the tenants decision making to engage or not to engage with the devices to seek support typically pervasive systems do not require active input from the user many participants were unsure of the use of devices when pointed to in their living environment this becomes a challenge when the tenant was required to use the device to seek support i fell about 3 weeks ago clumsy footless thats all it was pressed the button on the wall and its not because shes here again now but within 2 s 2 girls up to see if i was alright ann user activated technologies required the person living with dementia to remember to use such devices if they needed support urgently the challenge is for a person with cognitive impairment to remember how to request support when they need it well at the time i fell in the bathroom i was on the toilet and i got up and my head went dizzy and i fell but the way i fell i never remembered about the thing you the strings you pull you know bridget in addition participants reported choosing to interact with devices or not a commonly reported reason for not using the available technology to seek support within the tenants flats was because they did not want to disturb the staff i just dont like it its me i cant go and press it because i think theyve enough to do without coming up to me helen contrasting this view some participants report using user activated devices to demonstrate their knowledge and ability to use the surrounding technologies i always use mine even if its only for a simple thing i find its better to let the staff know that youre using it and you know how to use it elma technology enabling connection it was evident that technical devices kept participants connected both internally in the scheme and externally with family caregivers and friends monitoring devices such as wearable pendants and fixed alert systems enabled tenants seek out social and functional support from formal caregivers this enabled autonomy privacy and independent living alongside feeling connected to people that provide support if you need somebody some help youve only got to talk there and ask for help if you need if you had a fall or anything you can ring cords to pull you know bridget mobile phones were the most popular personal device reported the use of mobile phones enabled the maintenance of strong relationships with important social contacts such as families and friends my best friend is my mobile emma everyday technologies such as computers laptops and ipads were reported as a supportive mechanism to stay connected these types of digital devices were infrequently reported however it was often when family members lived abroad another person used their ipad to engage with a group developed to empower people living with dementia and engage in citizenship i got this as a present it is so easy it makes everything so easy you know for me now susan susan outlined that apps such as dragon dictate were useful to use speech typing as opposed to touch typing particularly when writing was no longer possible during the interviews participants in two separate schemes mentioned ipad training encouraged by staff within the scheme the cognition required to actively engage with technology was reported as a challenge in relation to digital devices that enabled connection for example it was difficult to remember passwords to log onto computer and the various accounts for socialisation such as skype email and social media i find skype easier than email i can skype them but he has set me up with a password and i have forgotten denise there was also a belief that technology was not something tenants were accustomed to and therefore not relevant at this point in their life particularly digital technologies to enable connection were not viewed as important to interact with im not a computerised person michael there was a sense of satisfaction with the care provision within the scheme and needs been met therefore technologies that support connecting to outside the housing environment were not required for these individuals they felt connected within the scheme one barrier to technology supporting connectedness was that wifi was not widely available to the tenants the lack of wifi unless purchased personally really limited access to online services that would enable communication between the tenant and their friends and family they have wifi in lots of places but they dont have it here i dont know why denise cross sectional survey of formal and informal caregivers a total of n 20 family and friend caregivers from six of the eight recruited schemes completed the survey of which 80 were female and 20 were male proving care for 52 years on average a total of n 31 staff caregivers with years caregiving experience on average from four of the recruited schemes completed the survey of which 1935 were male and 25 were female training was usual reported as an induction activity with 6774 staff reported completing it alarmingly ten staff members reported never having training to use the technology systems in the housing schemes informal caregivers widely reported the positive aspects of technology to support care in addition 8889 did not see any negative reason around technology use in advance of the tenants move to the schemes six participants were influenced by the technology available during the decision making process participants cited reasons such as i liked the way they use all the available aids such as sensors beside the bed to indicate the patient is out of bed the technology is useful for safeguarding thought it was more up to date and the degree of vigilance it gives it was also reported that quality of care the secure setting the care was needed regardless of what technology was available were among the reasons the scheme was selected as a housing option for their loved one technology was reported to impact the caring role for 80 of staff caregivers table 5 sets out an overview of the advantages and disadvantages outlined by caregivers a total of 55 family and friend respondents felt tenants should have access to internet 25 should not and n 4 20 didnt know it was also considered an asset to support tenants socialisation and families had installed internet in their relatives flat already interestingly 7742 of staff felt tenants should have access to internet 323 should not and n 6 didnt know responses against access to internet were around safeguarding issues for both caregivers attitudes towards to use of technology were captured and outlined in table 6 discussion global health priorities want to address the care needs for the growing number of people living with dementia the preference is for people to age in place with wrap around person centred care that supports choice autonomy and independence while complimenting the care received from formal and informal caregivers this challenge has the potential to be supported through technology innovation and alternative care models it is important to reflect on the entire dementia journey and explore the changing needs people have across the continuum of care this present study examines technology used to compliment person centred care in supported living environments from three stakeholder groups tenants informal caregivers and formal caregivers from a critical dementia lens the findings demonstrated that technology enabled people that were no longer able to live in their own home to have privacy independence and autonomy in a supported living setting previous research has indicated that supported housing can lack the resources and facilities to support the maintenance of independence and autonomy 32 technology could be the solution to support the resources required to empower tenants to live independently for longer and enable citizenship and social connectedness 11 finding the ethical balance between independent living and safety could be provided by digital monitoring technologies to meet the needs of all stakeholders 39 the main findings from the technology audit highlighted a wide range of technologies and devices operational within the technology enriched settings in line with gibson and teams 8 review the technology provision across the housing schemes was fragmented and often bespoke design meaning that no two facilities operated in the same way it was evident that schemes operated different policies around the free movement of tenants as some environments were locked while in others tenants held the key to the front door data from the technology was not widely used within the schemes as only two facilities reported using this information for individual care planning careful consideration should be given to the management and use of collected data 20 therefore the results would suggest that a clear plan to integrate the use of technology into caregiving for the future is required 57 equally enhanced staff training and discussion on implementation could further deepen knowledge and the use of devices and data in care delivery 58 technology such as sensors and wearable devices were provided according to the needs of the tenant indicating an individual and customisable approach which is a key feature of personcentred care according to the literature 33 shared learning across these facilities should be promoted to inform the ongoing operational delivery of care particularly on topics like gdpr and embedding data within notes and records to evidence how pervasive technologies inform care mobile phone use was commonly reported and supported feelings of connectedness within the tenant interviews this is in line with the findings of previous research 11 the findings highlighted very limited use of digital technology within the supported living environment overall opportunities for social interaction social robots and gaming technologies can provide a more holistic approach to dementia care 34 digital illiteracy is a significant barrier for this population 23 there is huge potential to harness the power of everyday technologies particularly with a more tech savvy generation that could be living with dementia in the future covid19 has changed this landscape research has demonstrated that with support from formal carers digital technologies for connectedness can support those with low digital literacy levels 44 the findings support the mixed economy approach to technology provision where off the selfsolutions compliment state provision 59 the interview findings indicated that tenants felt a sense of security and connectedness from the technology in the surrounding environment these are essential features for maintaining a sense of identity and being in a lived space 25 challenges included the need to remember to interact with a device and awareness of the pervasive nature of the monitoring technologies all tenants signed up to a tenancy agreement that included consent for using monitoring technologies within the living environment however there are ethical issues around informed consent with loss of awareness overtime 43 advanced care planning post diagnosis of dementia should include information and discussion on these types of accommodation so people can have explicit consent in place and triggers identified to support the transition from home to these facilities there was evidence that a needsbased approach was taken in term of technology use as is a key component of assistive technology and telecare provision 6 however no mention of an assessment to tailor the technology provision was evident in line with previous research 15 and the ethos of person centred healthcare provision we recommend a comprehensive assessment of need is undertaken additionally it is important to consider the tailoring of technology can this be undertaken by staff or does a person with expert knowledge need to be a part of this assessment the caregiver survey findings also indicated that attitudes towards the use of technology particularly access to wifi are still paternalistic and further percolation around this is required so people living with dementia can enjoy the benefits of technologies for social interaction gaming cognitive stimulation and leisure rather than purely healthcare lessons learned from the covid19 pandemic demonstrated the value in digital technologies for connectedness wellbeing and cognitive stimulation 11 once again this element of safety reduction of risk and protection from harm was highlighted as a core element of technology use 60 in line with the findings of hall and team 40 safety was considered more important than right to privacy the survey data captured key challenges for staff that included the high volume of calls false alarms and its failure to work in certain parts of the building only 1111 of staff felt there was a disadvantage to using technology such as tenants not remembering how to use it and that it could go wrong these fears were very much consistent with previous research 61 a limitation of this study was a focus on supported living in a single country in the united kingdom it is difficult to know if experiences are transferable across to other settings in different regions particularly given the unique nature of technology provision across this single country response bias could be present in the data as scheme managers identified the tenants to engage in the recruitment process for interviews the low response rate for the survey could have been because of caregivers lack of awareness of these activities even with electronic and hardcopy distribution the housing schemes had capacity challenges and it is possible this resulted in only half undertaking the follow up phone call to complete part b of the technology audit the use of technology in this living space by multiple stakeholders is complex future research using a longitudinal ethnographic methodological approach is recommended to future explore these relationships in addition as the digital literacy of people moving into supported housing changes it would be interesting to explore the capability of everyday technologies to support the caregiving relationship from diagnosis and throughout the continuum of care and changing housing models the present study provides new insight into stakeholders experiences of living working and caregiving alongside technology in supported living environments it was evident from the literature that choosing the correct technology to support people living with dementia in supported living environments was multifaceted the current study highlighted the diversity of technology provision and often opportunities for housing schemes to learn from each other were overlooked elements of personalised care and personcentred practice were apparent with customised approaches to technology provision where tenants were aware they were living alongside technology it provided a sense of security and connectedness these findings highlighted the importance of advanced care planning and technology assessments earlier in a persons dementia journey equally providing support to harness everyday technology to sustain ageing in place and support caregiving is important the findings also indicated that attitudes towards the use of technology particularly access to wifi are still paternalistic and further percolation around this is required so people living with dementia can enjoy the benefits of technologies for social interaction cognitive stimulation gaming and leisure rather than purely healthcare additional file 1 additional file 2 authors contributions jdl lead on the implementation of the project the acquisition of data interpretation of data and the development and drafting of the manuscript ar had substantial contribution in the conception and design of the study interpretation of the data and involved in the drafting and revision of the manuscript bmc had substantial contribution in the conception and design of the study interpretation of the data and involved in the drafting and revision of the manuscript sm had substantial contribution in the conception and design of the study supervised the acquisition of data interpretation of the data and involved in the drafting and revision of the manuscript all authors contributed to the development of the manuscript and gave final approval to the version submitted competing 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background technology innovation provides an opportunity to support the rising number of people living with dementia globally the present study examines experiences of people who have dementia and live in technology enriched supported care models additionally it explores caregivers attitudes towards technology use with the housing scheme methods a qualitative research design was adopted and eight housing schemes consented to take part in the study a technology audit was undertaken in addition to participant interviews and caregiver survey seven peer researchers conducted semistructured interviews with 22 people living with dementia interviews were analysed using thematic analysis informal and formal caregivers were invited to complete a survey to capture their attitudes towards technology use a total of 20 informal and 31 formal caregiver surveys were returned all surveys were input into survey monkey and downloaded into excel for analysis closed questions were analysed using descriptive statistics and openended questions were organised into themes and described descriptivelythe technology audit identified that technologies were in place from as early as 2002 technology heterogeneity of both passive and active devices was found within the housing schemes technologies such as wearable devices were reportedly used according to need and mobile phone use was widely adopted the themes that developed out of the tenant interviews were attitudes and

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introduction a historical perspective on the relationship of cultural anthropology and psychology cultural systems of meaning seem to play a crucial role in mediating the relationships between caregiving and child behaviour suggesting the very real possibilities of a cultural psychology that combines the best of anthropological and psychological methods and disciplines when we read this quotation we are repeatedly struck by the cautious wording used by emde and spicer in the year 2000 to refer to the role of culture in care and child development as well as in prevention science this caution culture seems crucial suggesting possibilities of a combination of the best of psychology and anthropology shows that no longer than two decades ago there was still a long way to go at the level of interaction between anthropology and psychology before the creative possibilities of culturesensitive methods within psychology and preventive science could become clear as mentioned by von klitzing very recently in 2019 a systematic reflection on and description about what it concretely means to work in a culturally sensitive way still needs to be done it has already been more than four decades since fraiberg et al launched the concept of developmental guidance we called this form of treatment developmental guidance in which the therapist becomes a nondidactic educator of the mother as to the physical and emotional needs of her baby and the ways in which a mother can provide these needs it is guidance in nutrition and in child development the practice of care for the physical and emotional needs of the baby to which fraiberg et al refer as well as the granting of meaning to the preverbalbodily communication of these early needs have ever since received the attention they deserve in prevention science and in psychoanalytically oriented psychology in the 1980s the intention was to gain an insight into certain early developmental factors which had possibly played a role in creating problems that emerge later on in childhood or in a subsequent phase of life from the onset of developmental psychopathology this psychoanalytical perspective was introduced in a broader psychological scientific perspective the study of the earliest motherchild unit within a developmental psychopathology perspective as a part of infant psychiatry and infant mental health care the early detection of signs of maladaptive development or of development under stress was linked to the idea of developmentally based treatment once the possibilities of this kind of intervention became sufficiently known research into the earliest motherchild relationship was further intensified within the broad scope of psychology the fields of developmental psychology and developmental psychopathology have devoted much attention to contextual influences on child development in studying child development in context however the cultural dimension remained one of the least developed contextual aspects as emde and spicer made clear in the year 2000 for its part as long ago as the nineteen thirties and forties cultural anthropology pointed to the influence exerted by culture on early care practices and on the effect which this early care in turn had on the emergence of certain character traits and personality characteristics within a certain culture the discussion was often held in terms of shared national characters or basic personalities which were reproduced within a certain culture through upbringing without making any reference to the influence of specific subcultural differences or of family systems and individual differences in this process recently however anthropology has embraced a more complex model partly in response to this criticism here attention is also devoted to the influence which culture as a symbolic meaning system has on the more individual meanings that are given to social processes and relational dynamics within which the care of children takes place and through which cultural influences are exerted through these evolutions psychology and anthropology converged where anthropology came to think of culture as more differentiated by involving systemic and individual levels in a culture psychology paid more attention to the cultural which forms an important dimension of these systemic and individual processes this conceptual rapprochement between psychology and anthropology should now also be translated into practice including in the field of preventive development guidance preventive projects in infant mental health within a multicultural world sensitivity to the cultural dimension in preventive developmental guidance is of the utmost importance for western societies today because they are characterised by increasing multiculturalism as a result of immigration and globalisation many of the children currently participating in preventive developmental guidance programs in the major towns and cities of the western world are growing up in cultural or subcultural environments which differ fairly substantially from those of middleclass families mostly from caucasian origin during the first years of life these children from nonwestern families have crucial interactions which are given form and meaning by widely varying cultural environments these have been brought along within the immigration and keep their influence in the country of arrival at the same time these cultural meaning systems of origin are changing based on their own dynamics of transformation and change as well as in interaction with newly encountered cultures over the course of the first 3 years of life intense bodilyaffective communication and the initial acquisition of language are within the context of immigration substantially influenced by various cultural systems those of the country of origin and of the country of immigration for example nonetheless precisely in this phase of life for reasons we will describe later the culture of origin of the parents or grandparents of the newborn plays a very crucial role the prenatal phase and the first years of life are particularly suitable for observing the influence and importance of these cultural roots at work in the practices and communication of the parents and grandparents in question as well as in their internal representations which form the indepth psychological foundations of these practices and communications moreover this strong influence from the culture of origin during the first years of life certainly applies not only to poorly acculturated or newly arrived mothers as is sometimes alleged even more integrated mothers perceive this phase as a return to or a reimmersion in their own motherland in the widest sense of the word surprisingly enough this meaning system that is rooted in the cultural lifeworld of the land of origin is not often systematically integrated within western based preventive guidance projects the meaning attached to origin and descent also helps define for example the identity assigned to the baby at an imaginary level even before its birth within its family and in the wider sociocultural environment of which that family forms part in this sense the imaginary child the intense preverbal affective communication and the first words exchanged between parents and baby in the first years of life form the privileged domains for the intergenerational transmission of the cultural lifeworld of the country of origin from the parents or the grandparents the transmission of this nonwestern cultural lifeworld takes place at the same time as the process of acculturation within these migrated families a central point in our argument is that during the first years of life these families are extremely sensitive to issues such as roots and integration origin and future continuity and discontinuity in the cultural identity in this paper we will specify how at the time of the motherhood constellation and during the period of zero to three the sensitivity of parents to their cultural lifeworld in the land they left as well as their wish to introduce their newborn in a new cultural context is dealt with over the course of the preventive developmental guidance program first steps an important aspect of valuing cultural lifeworlds of origin is the acknowledgment that culture history and identity that is brought with in the immigration process are sources of strength and resilience for immigrant and asylumseeking families in the process of meeting and integrating newly encountered cultural lifeworlds1 setting up preventive developmental guidance for immigrated parents and their babies in brussels multicultural quarters the first steps project firstly we provide some information about the history of the preventive project implemented originally in the families house a community centre for preventive medical and mental health care in kuregem one of the poorest quarters of the belgian capital brussels kuregem is predominantly characterised by an immigrant population currently over 85 of the residents are of foreign origin and this percentage continues to rise a wide range of cultures of origin the first steps thus was implemented in belgian districts that have been infamous for generations for their poverty and low social status the first location of first steps in kuregembrussels is a quarter that attracted immigrants since the end of world war ii the first ones were italians greeks portuguese spanish and polish immigrants soon to be followed since 1963 by immigrants from other countries around the mediterranean sea all of them so called guestworkers from morocco turkey algeria and so on after 10 or 15 years some have found success on the socioeconomic ladder and left this disadvantaged quarter of brussels the places left open by the leavers since the beginning of the nineteen eighties have been occupied on the one hand by new turkish and moroccan immigrants coming to europe for family reunification or family formationmarriage migration and on the other hand by new groups of immigrants coming for political reasons the latter group of immigrants came from many different directions eastern europeans specifically from the former yugoslavia and former sovietunion and immigrants from subsaharan africa particularly the congo a former belgian colony cameroon niger nigeria ethiopia eritrea sudan and rwanda form the largest subgroups among these immigrants recently more iranian iraqi syrian palestinian eritrean sudanese and kurdish asylumseekers also arrived in kuregem as did afghani families not infrequently bringing with them a history of suppression civil war and terror as a result of dictatorship political instability or farreaching lawlessness in their countries of origin in addition to economic immigrants and political refugees kuregem is currently also the residence for romany gipsies coming chiefly from slovakia and romania where they have been marginalised and threatened with ethnic cleansing since the fall of the communist regimes and the upcoming of nationalists tendencies or by parts of turkish or moroccan families that since 50 years have been living in southerneurope and now seek support in northwestern europe in the aftermath of the bank crisis in countries like greece spain portugal or italy since 2010 early developmental pathways of immigrant children developmental vulnerabilities and their relationship to problematic school trajectories later on in childhood and adolescence in the past quarters like kuregem have often been seriously neglected by national politics and local representatives until recently unless they apply for belgian nationality and have acquired this several years beforehand immigrants and asylum seekers had no voting rights and therefore did not seem a priority at political level this discrimination led to a situation where investment in kuregem was only forthcoming when serious rioting broke out among adolescents and young adults who were stuck in particular ghetto schools andor became unemployed on a large scale during periods of economic crisis or during economic recovery could not benefit from the situation nonetheless such outbursts were only the tip of the iceberg the underlying problems were much broader and occur much earlier in the lives of young immigrants in the form of developmental problems during childhood from international pisastudies we know that countries like belgium and germany have a school system with a rather good outcome but both countries do not succeed enough in breaking down social inequalities in the course of the schooling period for example recent studies on children in immigrant families starting elementary school show that they lag behind in terms of social skills language acquisition and cognitive development in the early stages of elementary school a not insubstantial number of these children are also already showing evidence of learning problems and emotional difficulties while problems of adaptation to the school system clearly increase from the age of ten onward as far as learning difficulties of children with an immigration background are concerned we see the following in belgium by the age of 10 12 of girls and 21 of boys are already 1 year behind at school compared to only 3 and 5 of middleclass girls and boys without immigration history out of a group of 234 immigrant children born in kuregem in the year 1995 21 boys and 53 girls completed general secondary education without having to repeat a year in 2013 which is approximately 30 of these children for middleclass children this number is at 67 ten of these twentyone boys began courses at a college or a university seven of them completed these courses sixteen of the fiftythree girls began studies at this level fifteen of them also completed them of those with an immigration background who did not complete general secondary education a majority took some form of vocational education although a considerable number of them mainly the boys did not complete the training as they became demotivated and dropped out it is also a known structural problem in belgium that young immigrants with the slightest academic problem are immediately referred to the lowest educational level without being spread among the intervening levels dropout in school between 16 and 18 years of age is found by 23 of the youngsters with an immigration background in kuregem compared to 7 of youngsters without an immigration background the departure from normal academic development paths becomes very clear to many of the teachers and parents involved in the second part of elementary school and during adolescence but the process sets in much earlier however the early signs of problematic development in the first year of elementary school or even earlier at kindergarten and in early childhood are much less obvious good tools for the early detection of these signs are therefore needed these could be slotted into preventive programs which are aimed at as wide a target group as possible particularly because this target group as a whole remains a risk group today even if in the meantime some changes have occurred the number of children with an immigrant background completing school for example has indeed significantly increased while access to college and university is also higher compared to the previous decades this does not alter the fact that even today the number of children quickly falling behind at school andor experiencing socioemotional problems remains disconcertingly high in this and similar districts certainly when an immigration background is combined with low ses the results of our first studies in this respect have encouraged policymakers in belgium to consider the importance of the early detection of developmental problems and of preventive action the first steps is one of the initiatives that are supported financially in this respect promoting adaptive early development thereby preparing children for integration in preschool at age 3 and in elementary school at age 6 the aim is to offer these children more fair chances in school by preparing the socioaffective cognitive and linguistic basis for entry in school first steps as a firstphase intervention within a stepwise guidance approach throughout childhood and adolescence the developmental preventive program first steps in belgium has been built up step by step the most intensive programs are aimed at parents and their children from zero to three parents with an immigration background most of them with origins around the mediterranean sea minor asia or subsaharan africa are mostly not in the habit of systematically placing their children in crèches and with babysitters during the first 3 years of life they are more likely to look for support for raising children within the wider family context or with grandparents care in crèches or with childminders is also mostly difficult to afford for underprivileged parents the first steps then like many comparable programs in other countries is an early opportunity for parents to bring their young child in contact with an extrafamilial learning environment before the child enters preschool for parents with preschool children aged between 3 and 6 years old a followup program second steps is provided this involves fortnightly or monthly meetings which are absolutely essential for consolidating certain effects of the early program since children between the ages of 3 and 6 usually go to preschool during this period the parents more often come to the meetings without their children parenting growing up children becomes an important topic in second steps further followup is possible within the third step of the stepwise intervention further steps for parents and children during basic school and youth steps weekly meetings on saturdays for adolescents with an immigrant background as well as monthly meetings for their parents during evening sessions in the week methodology of preventive developmental guidance in first steps three ports of entry into the early parentinfant relationship the preventive project first steps consists of three subprojects • the first steps • the first words • bon appétit these three subfields educationdevelopment language and nutrition serve equally well as windows of entry on the early relational dynamics within which children develop the counsellors in the three subprojects therefore devote the majority of their attention to the affectively relational dynamics within which upbringing takes place and language is acquired if problems arise in one or more of these subfields the affectively relational bond between mother and child during infancy and the toddler years also presents a preferential window for intervention emde et al describe this kind of interventions as early relationshipbased interventions with the attachment relation as the central working tool for fostering socioemotional cognitive and linguistic development in order to reach the target group to the greatest extent possible information is disseminated at various levels firstly the building where the first steps project is located also houses the local prenatal and postnatal health care centres run by the two organisations recognised by the belgian government in this field kind gezin on the flemish side office de la naissance et de lenfance on the frenchspeaking side as a result of this shared location most of those in the target group pregnant and new mothers and their partners from this district come into very early contact with the first steps prevention program secondly the developmental counsellors of first steps attach the utmost importance to build networks of caregivers and organisations in the quarter the project is running thirdly a weekly presence amounting to half a day in the crèches and nursery schools in the district also means that many parents can become familiar with the project via this route in addition the developmental counsellors in first steps do everything they can to announce their project in general practitioners waiting rooms close collaboration with doctors and paediatricians midwives nurses crèches and childminders means that many concerns from parents about the development of their children reach the project counsellors fourthly it is of the greatest importance for the participation of immigrant mothers in the project that some key figures in their immigrant community become enthusiastic about this project these key figures are often people who know a lot about concerns and problems within families in the neighbourhood and can refer these families to the project fifthly our developmental guidance fits in closely with certain programs which have been developed by universities in the countries of origin of these families and implanted in belgium such as the mother and child education programmes they often find acceptance among turkish and arab immigrants but are very specifically targeted at five or sixyearold children and are more cognitively learning oriented in comparison to first steps with its focus on communicative and affective backgrounds of early social learning processes sixthly first steps is part of a larger network of nursing facilities preschools elementary schools and secondary schools as well as services for home observation and consultation in these networks the nursing and teaching staff members are brought together in twoweekly reflective supervision groups on themes such as creating equal chances through developmental guidance and school teaching or cultural sensitive work with children and parents from immigrant and refugee families these reflexion groups for professionals in nursing services and schools are organised by the counsellors and therapists of the first steps project whereas the home consultations are organised by another autonomously working organisation that is also part of the local prevention network seventhly besides the core business of the first steps project there was a possibility for the participants to have individual consultations in order to discuss some very personal questions and problems or to talk about topics that could cause shame and embarrassment in case of disclosure within group meetings in a context where the level of social control can be high group work as a method cultural meanings and embeddedness of the gathering of mothers to talk about children and upbringing the groups in the developmental guidance subproject of first steps consist of six to eight parents and their children meeting together every week for 2 to 3 h there are various types of groups • motherchild groups • mothers groups • three generation groups • observation and exercise groups a fatherchild group was originally also set up but was not able to continue due to work constraints of the fathers that were involved yet as a result of this attempt a number of fathers did develop the idea of remaining involved with the project in another way some fathers bring their wives or children to the groups others stay for the first 15 min of the group session or come 15 min before the end of the group still others do all kinds of small jobs in the building where the project is organised a major source of inspiration for this project comes from the initiative taken by the french psychoanalyst françoise dolto in parts of paris with the opening of les maisons vertes open houses where parents come to talk about upbringing and development see aubourg paglia these houses are designed to be des lieux daccueil et de rencontre des espaces jeu et loisir and des espaces parole where parents can talk in the presence of their children and can share questions concerns joy and sadness about their children and parenthood des espaces de partage in turkish language these meetings are referred to by the term dertlesmek during the meetings in first steps these cultural habits are occasionally evoked the coming together of mothers thus becomes significant against the background of this cultural heritage in the meaning which these meetings have for mothers similarities and differences are perceived between there and then there and now and here and now what is it then to raise children here with a reference to the land of origin from which the grandparents emigrated one important additional aspect of this intervention is that these families are welcomed very explicitly at the beginning of each group session being welcomed and being able to participate is an important theme in the lives of every immigrant after 3 years of participation in the first steps project a mother of moroccan origin said that she now knew that there is something helpful for us immigrants here within this society she added that before participating in the project she doubted about really being welcome in belgium first steps made her realise that also the children in immigrants families can obtain support this mother also became aware that her own perspective on the guest society had changed in a positive way as she expressed it i feel more attached to this society now some of the parents we contacted several years after participation in the program mentioned that their experience of getting more equal chances and help for their children was interiorized and guiding them at certain key moments later on when the developmental course of their children was under pressure at that moment they remembered very well that there is help for them and that they are not left alone with their problems this again is an important aspect on the way to more equality for the upgrowing children in immigrated families the meeting room as an embodiment of the linking of different cultural meaning systems the surface area of the meeting room for the motherchild groups is ideally approximately between 70 and 100 m 2 the room is divided into three sections of approximately equal size one area for meetings between parents one for children to play and one part for interaction between parents and children chairs are provided for the parents with stools in between low benches which are customary in countries bordering the southern and eastern part of the mediterranean sea the maghreb countries and in asia minor since the majority of the participants is from that region in between the chairs and benches are small low tables with all kinds of bowls and tea sets the setup of the meeting room is in some ways the same as the room in which guests are received in mediterranean cultures the small tables can also serve as workbenches for the children since they are low if they want to draw do puzzles or play near their parents in addition the meeting room for parents also has corners where children can be cared for or breastfed if the mothers do not want to do this in the group most of the mothers we meet in the project also spend parts of the summer holidays in their country of origin they often like to bring back a gift for the project childrens books toys or items and ornaments for the meeting room are extremely welcome as well as fruit and water which has been brought back from over there and is generously shared with the group in the first session after the holidays in this way an intercultural mix is gradually produced in the available toys and in the furnishing of the meeting room which reflects the widely diverse origins of the participants in the groups as well as the culture of the country where the project is running several play areas are provided for the children equipped with toys suited specifically to various ages between 0 and 6 each child has an individual drawer where all kinds of drawings can be kept as well as clay models things they have made themselves or brought along the toys include a lot of dolls as well as human figures with widely varying clothing and racial features furthermore there is also a wide range of animals drawing materials building blocks construction material cars a farm a garage a kitchen a dolls house a castle etc activity sets and maxicosi strollers are provided for the smallest children the room also has a wall cabinet with childrens books in various languages as well as books without text reading books together or reading childrens books aloud is an important activity for mothers and children together illiterate mothers who initially avoided the book corner can also get involved in telling stories using the books without text reading in front of children is also a means to immerse them in language between the play areas for the children and the meeting room for the parents where parents and children are often also present together is a transitional room for interaction between parents and children this is particularly where the motherchild bond during the first 2 years of life is practised this is the area where floortime takes place explicit attention is devoted to bringing about and maintaining communication between parent and baby stimulated by the developmental counsellor the parents learn to look at interaction with their children in a new way in order to recognise the positive aspects more explicitly and to reinforce them the intermediate space where this subtle interactional game takes place is separated from the rest of the room by a low plastic tape parents and children can go back and forth around this border between the meeting space for the adults and the play areas for the children without disrupting motherchild interaction during the floortime the developmental counsellors as facilitating environmental figures symbolising diversity within a multilingual social context the team of the first steps project consists of one male and two female care workers one of belgian origin and the others with immigrant backgrounds themselves the three counsellors are clinical psychologists social workers or educational scientists with a different ethnic background they are trained as psychoanalytical child psychotherapists andor systemic supervisors furthermore the project also involves translators or intercultural mediators particularly for parents from eastern european minor asian or subsaharan backgrounds the topics brought up for discussion during the group sessions are not fixed in advance the participants define them jointly the counsellor is present and fulfils the functions primarily of welcoming and containing heshe facilitates the coming up of questions about education child development and parenting in this sense heshe monitors the potential space for meeting each other and talking to each other around these topics the counsellor repeatedly reminds the group that it meets each week at a fixed time and that certain matters which could not be fully discussed can be brought up again the next time the counsellors also switch between the various subgroups in the meeting room or circulate between parents and children in the presence of the children the counsellor attaches much importance to structuring the play activities parents take over this aspect themselves in time they are strongly encouraged to do so as is the case with the managing of conflict situations between children over the use of toys these incidents are preferably discussed in the mothers group afterward where much importance is attached to comparable conflicts in the home situation and the roles of fathers and mothers in such situations making culture more concrete in the context of developmental guidance and infant mental health care attachment to culture of origin and the wish for integration within newly encountered cultural lifeworlds immigration is not a subject in itself in this project at the same time immigration plays an extremely important role in virtually all aspects of education and development so that this subject is always implicitly or explicitly present in the stories the mothers tell and in the questions they ask grinberg and grinberg describe immigration as a farreaching change more specifically as a loss of cultural selfevidence it is not culture that is lost it is the selfevidence of a cultural meaning system that is called into question immigrants can process this loss in a creative way in anthropological literature the results of this processing have been described as the emergence of a bicultural or twin identity a multiple or mixed identity these concepts from the acculturation literature and research make very clear that a process of coming to a creative biof multicultural identity does not exclude conflicts along that process and that in the end bior multicultural identity is at the same time attachment to origins and orientation toward integration in that process the richness of bicultural belonging is acknowledged while at the same time tensions and conflictual aspects of bicultural belonging are endured the less creative processing is expressed on the one hand in an obstinate clinging to everything from thereandthen which impedes any change in cultural identity on the other hand it is all too easy to be absorbed in a new cultural identity without leaving room for putting down roots in the culture of origin both figures of less creative identity finding in a multicultural environment are characterised by a reduction of the multiple into the singular realising that specific waves of immigration are associated with specific challenges vulnerabilities as well as elements of resilience a key moment arises in the family cycle with the birth of a new generation when even the most creative balance between continuity and discontinuity in cultural identity is itself again brought into question among parents for example the question remains of how they will introduce both cultures to their children we regard this as a general issue associated with the immigration process in addition a more specific question emerges that of the impact on the parentchild relationship of the specific waves of immigration from mediterranean cultures this immigration took place in stages or shifts from the beginning of the 1960s onward western european countries relied heavily on immigrants from southern europe north africa and asia minor to fill particular vacancies in heavy industry this first generation of immigrants was therefore made up of men they came with the idea of reemigrating earning good money over a few years in western europe then building a better life in their country of origin using the financial and material gains from immigration this remigration was repeatedly postponed as a result of the healthy economic situation in the 1960s and early 1970s only during in the summer months did these men often return to their families in their country of origin for a couple of weeks however things changed with the economic crisis of 1973 one year later in 1974 a ban on immigration the migrationstop was announced throughout western europe immigrants could now only come in order to reunite families this led to a feminisation of immigration when the spouses of the first generation of immigrants made use of this opportunity to support their husbands immigration projects those already in western europe no longer remigrated after all it was no longer certain that anyone going back would have a second chance at economic immigration to western europe around 1975 the spouses of the guest workers had in many cases become mothers in their country of origin before they came to europe when they emigrated they too did not intend to stay here long and with this in mind not seldom left their firstborn children with grandparents or aunts to be raised there among family members in the country or origin the idea was to leave the parents here with their hands free and to put their efforts into work for a further short period moreover leaving the children at home meant a counterbalance for the breaches and discontinuities which were experienced by both immigrants and those who stayed behind in the homeland leaving the children there during their early years was a visible sign that all concerned were convinced that the whole family would be together again there soon for some years the first generation of immigrants in western europe both men and women lived with the idea that they would remigrate within the foreseeable future and at that point would slot back in neatly with their own parents and children in the region of origin however from the beginning of the nineteen eighties it became clear that the migrationstop would not be lifted in the short term anyone who did nonetheless reemigrate was faced with a dilemma on the one hand as an economic migrant heshe could not then return to western europe on the other hand as a reimmigrant with more than a decade of absenceheshe was not always openly welcomed back at home in the meanwhile between 1980 and 1990 other children were born in the families of guest workers in western europe and were raised in a european context from birth on as a result of these macroeconomic circumstances and the evolutions of perspectives on migration within the community of origin of these immigrants over the course of the nineteen eighties immigration took on a more permanent character in response to this mothers in particular encouraged the older children to be sent over which again was made possible with a view to family reunification these children raised in the country of origin in the first years of life as well as their brothers and sisters subsequently born here are referred to in the literature as the second generation of immigrants the vast majority of the parents we have welcomed between 2000 and 2015 in the first steps project in belgium belong to this generation with the socalled second generation and their children that have been born from the end of the 20th century on immigrants became an ever more permanent part of the population in western european countries and the question of whether these cocitizens can be labelled any further as immigrants is justifiable since most of them are born and have been raised in western countries the grandparents men in particular still talk of going back but these remigration projects are increasingly being called into question as the children and grandchildren grow up in europe and are of course europeans themselves ultimately also most parents of the first generation remain with their children in europe in the years that went by since 2000 we could often hear that the position of the young men and women of the secondgeneration is not easy in turkish and moroccan immigrant communities since the ban on immigration was never lifted considerable pressure is exerted on the young men and women in these communities to marry someone from the country of origin of the parents nowadays importing brides and bridegrooms is a variation on the practice of family reunification only by marrying someone from turkey or morocco can young men or women from these countries who are not part of the european union come to western europe in a legal way family reunification has thus become active family formation or marital migration which again allows the ban on immigration to be evaded sociological research indicates that around 2010 approximately 50 of marriages in turkish immigrant communities currently take place in this way secondgeneration marriages usually take place during summer holidays in the country of the emigrating partner these marriages can be recognised by western european juridical systems then the spouse can request entry into europe as a form of family reunification however what is regarded from a western perspective as family reunification is a highly complex reality at affectiverelational level marriages with imported partners produce parent couples with widely varying socialisation histories which can occasionally make it more difficult to raise the next generation a good knowledge on this kind of mostly economic migration to europe and on the specific challenges that are associated to this kind of migration is important for a better understanding of the marital and educational questions that can arise in these families a woman from a turkish or moroccan family who has grown up in western europe and who marries an imported bridegroom often has to fend for herself during the first years of the marriage while the bridegroom tries to settle down here to some extent begins to learn the language and often has to work for some time below his level of education and moreover before they can afford themselves their own house is living with his motherinlaw the woman often is the major breadwinner the most efficient bridge between family and the outside world and at the same time is responsible for bringing up the children if a man who grew up here in an immigrant family imports a bride the woman must often go to live with her motherinlaw for some time this may well be in accordance with specific common traditions in this area as is the case in central turkish culture but nonetheless this tradition does involve certain risks in the context of immigration while the imported bride tries to adapt to some extent she not infrequently feels suddenly cut off from her own relatives who now live a few thousand kilometres away feelings of loneliness are often no stranger to these imported brides in this difficult situation such women not infrequently become firsttime mothers luyckx demonstrates that psychological and relational difficulties are far from infrequent in these marriages and it is no coincidence that this group mostly aged between 20 and 30 is proportionally overrepresented in residential infant psychiatry wards in flanders to which both mothers and newborns can be admitted there they regularly represent over 20 of the patient population with a postpartum pathology of a depressive andor psychotic nature moreover the age at which the young immigrant women we met in the belgian first steps project come to marry is significantly lower than that of other women becoming mothers for the first time the lower marriage age by western standards could indeed be inherent in the cultures of origin but forms a risk factor in an immigration context the social support from the extended family is by no means as selfevident as it is within the culture of origin immigration has after all spread extended family members throughout western europe so also raising children in an immigration context is more often characterised by loneliness and emotional strains for these young mothers adopting a multigenerational perspective on immigrated or exiled parents and their babies the cultural change caused by immigration has brought about certain socioemotional vulnerabilities the young mothers of the second generation often describe that they find insufficient identification possibilities in their mothers of the first generation with respect to the dialogue between cultures first and second generation mothers adopt a different attitude this is partly a result of the fact that the first generation of mothers from the 1970s to the 1990s did not come to europe until they were on average over thirty years old while the second generation had been here since childhood or birth the mothers in the second generation describe how they look elsewhere for identification figures particularly among contemporaries in age sisters cousins girlfriends however here too the feeling often arises of being left to ones own devices the impression is of being charged with the same task as other women of the same age but still of having to find ones own individual answer moreover secondgeneration mothers often have the impression that they would like to impart to their children aspects of the cultural background which they received from their parents but that their children of the third generation will inevitably be very different from them so that they do not know if they are doing right or wrong in raising their children in the way they do secondgeneration mothers thus often feel that they are on their own both intergenerationally and intragenerationally a point of identification between immigrant mothers of both generations emerges when the young mothers of the second generation realise that they are living with the same fear as their parents specifically the fear that their children will be different that their children will not consider their parents in their quest for an identification figure this is expressed for example in a high degree of uncertainty and indecision when the young parents have to make decisions concerning choice of school choice of language structuring and letting go of their children etc in conversations in the presence of the grandparents during sessions in the threegeneration group the young parents of the second generation recognise sooner or later that these fears were just as evident in the previous generation among their parents discussing this transgenerational transfer of concerns about the upbringing and development of children in a context of immigration and of the impact these fears and concerns can have on parents and children makes the group meeting into an important transgenerational event for those involved the fathers of the first generation were highly focused on remigrating and in that respect did not have the intention of showing their children or their wives ways to the broader western society however as soon as they realised that migration had become more permanent it was not so easy for them to change course the secondgeneration fathers are not infrequently just as insecure either because some of them dropped out from school in western europe or because as imported bridegrooms they have just arrived from their country of origin and it takes them some years to find their own way in a different cultural environment the insecurities of immigrant fathers are often discussed in the groups in the context of all kinds of upbringing issues particularly in their attitudes toward the school trajectory of their children the choice of educational language the representation of authority within the family these young immigrant or second generation fathers insecurities are brought sharply into focus in the parentchild groups and in the threegeneration groups extra attention is sometimes devoted to the strengthening of the fathers position in the family an additional element that needs to be mentioned in this context is the discontinuity that is experienced in the context of migratory processes most of the families in first steps are part of extended family networks that are dispersed over several european or other countries and that as a result of this dispersion have become transnational families the families we meet in first steps mostly present themselves as nuclear families very similar to what most families have become in the western world but in the context of the first steps meetings we soon found out that the other fractions of the familial network have an important influence on decisions that have to be made about child development in that sense our experiences in the project were also an opportunity to enlarge the ethnocentric point of view of our counsellors working from expectations that have originated in the context of western nuclear families a three generations perspective or an extended family or transnational family perspective was often present in the reflections of the parents within first steps groups like several other aspects that are described in this article these practiceoriented reflections are closely linked to the theoretical discussion we opened up from the beginning of this article how can we combine in a practiceoriented and at the same time theoretical way culturespecific and universal perspectives on child care and parenting working with differing cultural scripts regarding the emergence and resolution of mental health problems a great deal of consultation takes place at times of illness insecurity and doubt and equally at key moments in the family cycle as well as at times of crisis in some cases simultaneous consultations take place with western care workers and healers from the cultural tradition of origin for example the hoça for turks the fqih for moroccans the marabout for western africans these coconsultations are described in anthropological literature as medical pluralism or therapeutic hybridisation the parents in question do not talk very often about this simultaneous consultation in two therapeutic systems the mothers are by and large more likely than the fathers to invest in this dual practice but major differences also exist among mothers sometimes they explicitly say i am doing now what my mother did i do not know if what she did is right but nor do i know if it would be right for me to do it differently let us suppose that even if a mother of turkish or moroccan origin does not really believe in it she would not want to say that she had not sought all possible means of protection or cure for her child the significance of this coconsultation does of course differ from parent to parent but fairly often the recurrent theme in stories of these consultations is related to concerns regarding the vulnerability of a pregnancy and labour concern too about what can happen postpartum concern about vulnerability of babies and their parents and about being negatively influenced by invisible forces differing explanations for illness are put forward at such times of vulnerability such as the djinna or the evil eye in contrast to these we find ritual healing practices or türbes may be visited the consultations with hodjas fqihs or marabouts and visits to the türbe mostly take place back at home during the summer holidays but the healers can also be visited all year round in large western towns and cities the parents in question almost always think a great deal of the problem can be resolved by the western medical system however they also admit that this simply cannot eliminate all existential insecurity or ontological vulnerability for which they feel their culture provides an additional answer in preventive developmental guidance this presents us with culturespecific explanations about the emergence and course of illness as well as about healing and the role of therapists in magrebian cultures for example mothers can believe strongly in the evil eye which is often associated with bad suspicious jealous or angry others who will not grant them a healthy baby the suspect is often someone completely unknown or a relative of someone with whom the mother in question or her family does not get along this person is supposed to have cast an evil look to bring disaster or sickness upon the child this explanation binds together the fears for the uncertain or the indefinable which is strongly felt at times when a child is unexpectedly seriously ill for a long time this explanation for illness also offers a way out because it always provides an answer the mothers read passages from the koran for example recite fragments of religious texts carry out certain instructions and place protective objects by the child and near themselves rituals that go back in time into the preislamic period the task of the grandmother at such times is often crucial and placed within a broader social context she will try to see how the social background to the problem can be resolved or reconciliation can be achieved where the mother is focused more on her descendants the grandmother will try to bring about resolution within the extended family the broader social network of the immigrant community or even the group of origin who remained behind in the country of origin sometimes these beliefs and ritual practices are religiously influenced in other occasions they are part of local folk medicine for the counsellors within the prevention project it is important to have some knowledge on such culturebased explanations and practices as the ones described the meeting room as a potential space for weaving cultural differences into a containing and diverse meaning system by discussing these kinds of practices the meeting room of first steps embodies multiple cultural meaning systems that of the cultures of origin western culture as well as the intercultural collision the influence exerted by these three aspects of the cultural identity of the participants on education and development is repeatedly and explicitly discussed at times of insecurity and ambivalent fluctuation between different cultural influences care is taken to ensure that the intercultural or the cultural collision does not have a confusing or debilitating effect for the parents and children involved or that these parents and children do not fall between two stools in other words in this culturesensitive developmental guidance project the intention is to maintain a potential space in which the participants can explore aspects of different cultural systems and then incorporate them into a supportive and meaningful system of meanings and practices while the areas of conflict or the irreconcilability of the intercultural collision can also be discussed however oases of creative interculturality do occur when the parents feel they have been helped by the counsellors in recognising the support which their own cultural background continues to provide at times of change or crisis and in moments of intercultural dialogue once the desire for weaving threads to the culture of origin is recognised they can enter more contentedly into dialogue with other cultures in their environment with every step they take toward familiarisation with the cultural difference many of them will again want to strengthen their roots in the cultural tradition that has come along with the generations before them attachment to culture of origin and a desire to integrate newly encountered culture are both important dynamics in these young families with an immigrant background particularly during the period of imminent new life in the womb or after the birth with the child at home at the breast in the home at the hearth or at the table the influence of the culture handed down by the grandparents is particularly strong mothers not seldom speak to their babies in turkish or moroccan care for their babies as their parents taught them prepare meals which are only served in this welldefined traditional way during this period of motherhood constellation and alongside what the doctor has prescribed use all kinds of things passed on by grandmother to mother these traditional motherhood practices are most strongly supported by the counsellors in first steps they form a supportive matrix within which musings are possible about the future transformations in cultural identity of their children and of themselves once the children go to school particularly in the second year of life when not seldom breastfeeding stops thoughts occur more frequently about cultural change processes these thoughts become even more explicit if during the third year of life the childs first steps outside the house to school or temporary daycareare prepared for in the project quite often in this phase we also find that parents want to teach their children another language in belgium dutch or french which they will need during the forthcoming developmental stages this choice leads to ambivalence the parents know that it enhances their childrens developmental chances but are also afraid that precisely as a result the children could become strangers in the family at these times too parents and counsellors together look for ways in which the culture or language of the childs ancestors can remain present within the family once this is sufficiently guaranteed we see that many parents will give their children more room to learn another language and that they quite often go in search of language courses for themselves too both generations enjoying the acculturation processes within their own family conclusion from the beginning of our project first steps in the year 2000 culturesensitive infant mental health work interested us a lot we soon found out however that at that moment the concept of cultural sensitivity was still vague ever since we came to concretize cultural sensitivity in several ways for example by understanding parentinfant group meetings with immigrant families within the context of activities of parents and babies in the cultures of origin or by dressing the meeting room with objects ornaments play toys childrens books and furniture from different origins or by working with a divers team that embodies very different origins and speaks several languages we felt that these adaptations were important yet culturesensitive work requires more than only these transformations another way of working in a cultural sensitive way is to value differences in cultural beliefs or perspectives for example on what a child is and on how parenting is done or on the understanding of educational and developmental problems and on the kind of therapy or healing they need what parents recount in the meeting groups of first steps is understood as an attempt to weave cultural lifeworlds into a containing bior multicultural meaning system thereby expressing attachment to origin as well as a wish for acculturation and integration by doing so the parents try to combine the best of both cultural lifeworlds in an attempt to do as much as possible on behalf of the health of their offspring this part of the culture sensitive work is about bringing together different local or culturespecific ways of understanding childrens development in an attempt to rebuild a meaning system in the context of migration a kind of bricolage métissage or assemblage the need for such a bricolage is connected to what moro sees as a metacultural theory counsellors need to be aware that all over the world cultures have in common that they offer meaning and that they function as containment and that in the context of migration cultural meanings systems lose their selfevidence but dont get lost and can be rediscovered and transformed or adapted to new sociocultural environments in the context of immigration one needs to reweave different and specific cultural perspectives into a containing meaning system with all the creativity as well as the conflicts confusion or even moments of impossibilities within the intercultural encounter this can lead to to work with these cultural specificities means that we grant them an equivalent meaning on the symbolic level but at the same time that these culture specific perspectives are not more or less than emanations of universal aspects and principles of early parentchild relationships culture provides meaning and containment all over the world the way this meaning and containment is concretized embodied or brought into practice in daily life can be quite specific in the context of different cultures although the culturespecific expressions are an emanation of the universal function of culture this universal function of culture can only be realised through culturespecific expressions to conclude we can say that in order to work in a culturesensitive way within prevention projects it is important to emphasise the profound relationship between the global and the local perspective on culture or between the universal and the relativistic perspectives within cultural theories as an example of this we can refer to the given that universally cultural meaning systems offer a framework within which to raise children and that migration can lead to profound uncertainties about the culturespecific understanding of the parentchild relationship both the meaning system of origin as well as the newly encountered meaning system can feel uncertain within migration in the prevention group of first steps a lot of work is done to reweave these different culturespecific perspectives into a containing intercultural meaning system concretely this also means that culturespecific traditions and meaning systems of the immigrant families for example about motherchild bodily contact about breast feeding or sleeping practices are seen as enriching and equal perspectives or as practices that create a continuing sense of hold and grip within the new context they immigrated to in that sense first steps is not conceptualised as a oneway help for immigrant families with acculturation problems the project is rather seen as a mutual learning process where the developmental counsellors too come to value culturally rooted and culturally different perspectives on becoming a parent as well as on raising children 2 the search of von klitzing for a content of cultural sensitivity has now been resolved insofar as we have been able to 2 the guiding principles of the first steps project are tightly linked to the ten practicebased principles for effective early childhood mental health consultation services such as they have been described by iecmhc and waimh relationshipbased collaboration individualised culturally and linguistically responsive grounded in developmental knowledge evidenceinformed see meurs and luyten datadriven delivered in natural settings a continuum from promotion to intervention integrated with community services and support leave behind the sterile critique of cultural relativism on universalism as well as the ethnocentric point of view of some universalists we exceeded this sterile opposition by combining the best of cultural anthropology and of cultural psychology this in turn made it possible to find answers to emde and spicers quest for a integration of cultural sciences within infant mental health care projects that are suited for the needs of todays superdiverse world 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 copyright © 2022 meurs lebigervogel rickmeyer and jullian 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

preventive developmental guidance programmes have been applied on a large scale for several decades now in many western countries but how do we adapt these programs to families with very different ethnic backgrounds how can we concretise the concept of cultural sensitivity into that context the plea of von klitzing the former president of the world association for infant mental health for further reflection on the concretization of cultural sensitivity in the context of infant mental health care is the main source of inspiration to this article von klitzing speaks out against the point of view in which universal childrens rights or conditions that are seen as promoting a childs development all around the globe are criticized as being only western conceptions and thereby culturally biassed following this kind of reasoning a culturally relativistic stance on what a facilitating environment is should be adopted such a discussion in terms of universalism versus relativism though as argues von klitzing is an old antagonism that cannot inspire us for the adaptation of early health care practices or developmental guidance programs that are fitting in to the needs of families and their babies that are living in multicultural contexts although it could be interesting to think about how certain universal principles of goodenough child care can be formulated or embodied in an intercultural variety of ways these variable expressions of the worldwide agreed upon principles of good early mental health care will only be culturespecific translations of these universal principles they cant in any way be seen as an argument against the universality of these principles as argues von klitzing who is describing another way of solving the problem of the cultural relativist criticism on the universality of principles of good infant mental health culture sensitive infant mental health services but to make the principle of cultural sensitivity work in practice we need to fill it with content this article is mainly on what it concretely means to work in a culture sensitive way in our preventive practice within the first steps program a belgian project for immigrant and exiled mothers and their children from zero to three

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introduction for more than a century the forms of communication surrounding major international mega sporting events have been legion mses such as the olympic games or the array of world championships across athletic and sporting codes have provided pathways for nations and individuals to express themselves as well as convey strong threads of nationalism and internationalism through teams and individuals media coverage of mses showcases the sporting elite traditionally via controlled media coverage reaching a globalised audience through multiple communication channels however as noted by mcgillivray new technology has created opportunities for alternate content creators or citizen media to use the global attention directed toward the mse to draw attention to undervoiced social issues citizen media and the resultant hybrid media environment has altered traditional media gatekeeping with multiple uncensored narratives increasingly mse organisers have contributed to the social narrative by demonstrating inclusivity and equality and acknowledging the need to leave a positive social and environmental footprint for example planning and investment to achieve sustainability for the london 2012 olympic games resulted in the creation of a 45hectare biodiverse habitat and affordable housing from the conversion of the olympic village accommodation while athletes are intrinsic to mses and the social narrative they are governed by activismadverse regulations yet athletes are uniquely positioned as citizen journalists crafting their personalised narrative with their deep connections to social causes using persona studies as a lens this article identifies how the shifted persona of the athlete and their use of social media repersonalises the potential and real pathways to express sociopolitical positions and sentiments although there is an inherent value associated with an athletes visibility and reach few amateur athletes have notably tested the flexibility of the policies in place by using social media during mses for athlete activism the gold coast queensland australia was the destination for the mse the 21 st commonwealth games in april 2018 this event involved 71 nations assembling 6600 athletes through cg2018 we examine how publicly prominent individual athletes contribute to and extend the social cause narrative through their personal communicative activities on social media platforms a realtime approach was adapted to monitor and identify celebrity athletes who entered into discourse regarding sociopolitical causes during this mse only two athletes met this criterion during the 2018 event england diver tom daley and australian paraathlete kurt fearnley ao both athletes used social media to reach their micropublics a technique to draw together their own audiences beyond the past pathways of legacy media and directly aligned to their own selfpublicity and formations of selfpromotion this socialmedia connection cultivated and worked to visibly champion a human rights cause both athletes championed inclusivity and equality daley focusing on lgbti advocacy and fearnley on disability advocacy the approach taken in this work is focussed on deciphering how athletes share this activist public identity through these individualised techniques of extending both their ideas and their image the study is informed by the extensive research on mediatisation its relationship to individualised mediatisation and the valuable work by frandsen that extends how mediatisation is personalised through the online transformations of sport to fully investigate this transformed way that elite athletes negotiate personalised and public roles during mses this study integrates how these athletes are negotiating their heightened capacity to use both legacy media and their persontoperson social media platforms that castells describes as a new mass selfcommunication in a networked society we investigate the fluidity or movement between legacy media and personal communication athlete activism through active and engaged athlete citizenship potentially advances important social change this research addresses the gap identified by cooper et al and cunningham et al to identify evolving forms of situational sports activism through an interdisciplinary lens persona studies in its reading of online identity formation and public sharing provides the theoretical tools for an analysis of how celebrityathletes negotiate the movement of their ideas through online platforms the analysis considers how celebrity athletes work to shape the stories that are generated about them within a social causerelated community and into wider flows of media stories and an equally wider public persona studies persona studies encapsulates the representations individuals are constructing how these are being exhibited in the public sphere and the power and influence personalised narratives can have this compilation of imagery that is exhibited through various forms of media and curated for external audiences is known as the production of the public self the collective accumulation of this personal information dispersed across what can be called the presentational media forms of online culture which include websites and social media that create opportunities for individuals to represent themselves and present their own narrative some individuals particularly those that have a wider public presence have created opportunities for their personally produced and curated information to flow from their presentational media activities on social media into traditional representational media or what is now often called legacy media such as television radio magazines and newspapers social media platforms facilitate information intersections blending our interpersonal media communication and profoundly intercommunication worlds other related research has identified how greater aspects of our cultures are now mediatised for lundby couldry and hepp and specifically in the domain of sport frandsen mediatisation has transformed both our regular forms of personalised engagement and even our politics in persona studies mediatisation refers directly to the way our public identities via online culture reshape us through text image and the sharing of other media forms at a level that is relatively new because of its pervasive deployment by billions mediatisation represents one of the key dimensions of persona as the personal is reconstructed through this now complex individualised mediatisation as we curate our online identities on social media platforms our analysis that follows explores this specific process of selfmediatisation by elite athletes as they shape their personal narratives into political and social causes we integrate into the analysis how these activist athletes negotiate a horizontal massselfcommunication by managing social power now represented by social media platform persona work with the topdown or vertical power of traditional media to move their ideas opinions and stories our study investigates how elite athletes work to make these forms of mediatisation and communication intersect in valuable and potentially powerfully influential ways from a persona studies analysis intentional value identifies one of the dimensions of analysing contemporary persona where an individual works through the personal mediatisation of social media platforms for specific objectives and ends persona studies provides a lens to explore this intentional value through a mapping of the kind of value agency reputation and prestige that athletes display through online presentation of the self this aligns to the earlier work of goffman and the presentation of self goffmans model considers the staged performance which in the case of the sporting eventarena provides the opportunity and setting for athletes to demonstrate their sporting excellence yet when not competing the athletes as actors can craft an alternative narrative which audiences can engage with through social media intentional value of athletesactors can be examined through mapping online personal presentation value identifies the relative worth cultivated by an individual through online representation agency pertains to active and engaged individuals who works towards wider cultural transformations reputation and prestige are interlinked and incorporate the reach visibility influence and power individuals can utilise through different connections and constellations of collective identity athlete activists can leverage their value agency reputation and prestige to influence or disrupt a narrative by focusing on elite athletes at mses we examined how they blend traditional narratives of their athletic performance with personal narratives with sociopolitical underpinnings athletes demonstrate how it is possible to cultivate parallel and alternative identities or multiple personas when the platforms of forming publics what current persona research has called micropublics have moved into and through the networks of personalised online cultures with equal or greater impact than traditional and legacy media formations of cultural influence athlete celebrities as much as we all construct personas elite athletes move into a different realm of mediatised visibility as their performances appear across media platforms and they become essentially celebrified from one perspective traditional media helped construct highly visible athlete celebrities by providing audiences with news about on and off field behaviours the portrayal of athlete celebrities was once dominated by the sports media narratives however with the introduction of social media we have subsequently seen an emergence of athletes taking ownership of their own narrative by actively using social media to enhance their visibility and attain recognition toffoletti and thorpe see personalised social media as an opportunity for athletes to craft their brand and selfdisclose multiple aspects of their authentic self this individualised activity can be explained by the term microcelebrity as it moves into collectives that are no longer defined comprehensively as a unified public sphere individuals can amplify their popularity through their online performance and respond to their communities rather than rely on the visibility afforded by traditional media athletes resourcefully use social media platforms to cultivate their own narrative and generate micropublic followings sports athletes have become another type of social media influencer as individuals that work to maintain both their significance and connection to their core followers through a key shared interest athletes can leverage their influence to channel positive and professional behaviour into a form of athlete citizenship potentially leading to constructive societal outcomes athletes utilise the visibility of their sport or mse as platforms or sites to engage in political activism in hopes of shedding light on societal issues this form of affective power amplifies and legitimises the athletes significant voice affective power cannot be measured by the number of followers a person has but we can use follower data to get a sense of the athletes potential influence for example when contrasted against the average twitter or instagram account which ranges between 180 240 followers amateur athletes with between 47000 and 22 million followers begin to illustrate the potential influence they could assert within their audience however the affective power of professional athlete celebrities currently in the public sphere who can amass followings in excess of 70 million would be significantly higher prominent athlete activism for social change has been witnessed at mses such as the 1968 olympic games podium protest and kaepernicks 2016 anthem kneel in their discussion and classification of sports activism cooper et al state that all activism is sociopolitical in nature whereby actions can range from specific policy and legislative reforms to more broad based calls for change including a critical analysis and reconstruction of takenforgranted norms and attitudes within hegemonic systems mses present an opportunity for activism yet they are highly politically controlled and some forms of activism such as podium protests are in direct conflict with some mses policies for example the olympic charter states no kind of demonstration or political religious or racial propaganda is permitted in any olympic sites venues or other areas the commonwealth games federation constitution outlines similar behavioural expectations governed through clear policies the commonwealth games through the cgf seek to demonstrate integrity global impact and to champion athlete citizen and community engagement as such these mses reconstruct this idealised conception of individual to cultural value through their mission statements in this way the sporting events mission works to subsume the individual into these high ethics competing athletes sign a membership agreement outlining various terms and conditions when accepting their place on a team one clause for australian athletes is no demonstration whereby athletes agree to the following statement i agree i will not throughout the games period make statements or demonstrations regarding political religious or racial matters and acknowledge these are contrary to the objects and purposes of cga cgf and the spirit of the games despite this clause the cgf regard athletes as change enablers the significance of the athletes role is addressed by the cgfs strategic plan which seeks to change the world for the better by upholding and living its values of humanity equality and destiny and encourages athletes to use actions words and deeds to inspire fairness inclusion and respect for the individual regardless of gender ability faith sexuality or colour it is important to also realise that the traditional athlete persona at the commonwealth games with their performance and relative silence of self on behalf of their country is actually an implicit political persona that represents the ideal of the nation and their constitution of a model citizen as a sports hero working within the bounds of the cgf constitution conflict has the potential to arise when an athlete seeks to become an ambassador for social change athletes participating in mses are reconfigured into a different persona that goes beyond athletic prowess into a territory that links the athlete to all sorts of representative collective configurations their link to their home country shifts the athletes public identity into something resembling a diplomatic persona their personal views may be in contrast to their nationstate limiting freedom of expression prospective athlete citizens are thereby constrained by policies and silenced by the passivecompetitive national politics of games like their entertainment celebrity activist counterparts athlete celebrities are embracing the reach they have through social media platforms and they too are drawing attention to sociopolitical issues soft activism is a term introduced by palmer whereby athletecelebrities use nonconfrontational social narratives to influence social change societal issues are amplified through athletecelebrity online personas whilst leveraging the mses international media exposure however there are factors that could convince an athlete to approach athlete activism with caution elite athletes are projected as role models carrying expectations of high standards of behaviour and moral conduct as such athlete activists have additional levels of stakeholder scrutiny the sport persona and particularly those derived from athletics and international games competitions faces different risks and disincentives than other public personalities in presenting their cause hartmann and smith et al discuss the multiple barriers faced by athletes seeking to advocate for social awareness including navigating the formal and informal rules pressures and norms surrounding organising bodies clubs sponsors other athletes and audiences in considering why many athletes remain silent cunningham and regan expect that athletes consider whether it is their responsibility to be advocates for social change and the potential monetary loss associated with activism olympic or commonwealth games athletes do not have the same financial rewards as professional athletes eg professional golfers amateur athletes selffund to reach the level necessary to represent their country which then provides potential access to commercial opportunities it could be argued that the commercial incentive is the only lucrative path for amateur athletes and this is reliant on representation and successful performances at mses to risk exclusion or expulsion from mses by participating in athlete activism could be financially damaging mse policies seek to limit opportunities for athletes to express politically charged comments by providing strict guidelines on acceptable content athletes reduce reputational risk if they only comment on their sporting performance and experience athletes must be mindful that personal opinions published in the public sphere have the potential to be accessed and unfavourably repurposed for journalistic materials authors documenting risk associated with athlete activism note that athletes are expected to play and not protest however this past assumption is being challenged as athleteonlineidentityagency has altered how we view athlete value social media technologies have provided athletes with a vehicle to present more aspects of their identity and advocate for political and social causes close examination of the gc2018 media coverage revealed alignment between athletes and social issues this article takes a focused look at how two athletes used the cg2018 as a stage to leverage their social impact value something that is distinctively differentiated from other social media influencers persistent push to economic value and promotion method content analysis of traditional media television and print were used to identify sociopolitical causes arising at the cg2018 and to identify amateur athletes competing in the commonwealth games who are championing these causes this took place in realtime by monitoring major australian print news such as the courier mail the australian and the local paper of the host city the gold coast bulletin plus channel sevens television coverage of the cg2018 as a supplementary search the database newsbank was also used news media was monitored during april 2018 for sociopolitical causes raised at the mse and any connections linking the mse and competing athletes one researcher monitored the named channels for any stories that focused on key sociopolitical causes as identified by gold coast 2018 commonwealth games corporation including cultural awareness accessibility inclusivity and gender equality the realtime approach was adapted from vardaman et al whereby the researchers examined the themes that emerged from traditional representational media during the mse this reflects a similar approach by finlay who selected case studies based on elite athletes pushing their messages directly into social media and major media organisations pulling a select few into the spotlight when a sociopolitical cause was identified the issue was examined closely to see if there was a connection made to any athletes by traditional media themes connecting societal issues with specific celebrity athletes were monitored across traditional news media and social media as the stories unfolded the public social media accounts of those athletes identified were then examined to determine if the athletes themselves supported these causes and how they personally joined the narrative this included all publicly available social media used by the respective athletes only participating athletes publicly supporting a sociopolitical cause through social media were included in the sample once the athletes were identified an examination of their public social media was conducted our analysis was guided by previous research examining athletes use of twitter selfpresentation techniques using twitter and the emerging examination of the use of instagram unlike previous research where a larger number of athlete profiles were included or a limited number of posts examined all content that was posted by the selected athletes during april 2018 was included in the data set athletes presentational media were classified according to selfpresentation descriptions of front stage and backstage to investigate online representation this research adapted hulls adaptation of goffmans model front stage coding included engagement with fans the promotion of stakeholders and the reposting or reproduction of information created by the mass media backstage coding incorporated observations that the athlete made about their sport fan behaviour that the athlete exhibited and behindthescenes insights a second coder independently applied the coding frame and agreement was reached once data was sorted according to front and backstage classifications we focused on how posts articulating a social cause narrative flowed between presentational and representational media and how they articulated value agency reputation and prestige as core dimensions of persona studies analysis the commonwealth games 2018 the gold coast queensland australia was the destination for the cg2018 which took place 4 15 april 2018 this twoweek mse involved multiple sports and participation from 71 commonwealth nations the organisers gold coast 2018 commonwealth games corporation were responsible for assembling 6600 athletes and 15000 volunteers it was promoted as the largest sporting event to be staged in australia this decade and featuring the largest integrated sports program in commonwealth games history comprising 18 sports and seven parasports parasport facilitates inclusion of athletes with a disability and allows athletes to compete with other athletes that have been classified as having similar impairment attendance across the cg2018 can be represented by the 121 million tickets sold extended audiences could view events via television or broadcast apps which further identifies a potential 15 billion viewers of the cg2018 goldoc also reported 113 million web page views of the designated cg2018 website and when combined with social media channels had around 733600 followers and more than 1083 million impressions a newsbank database search revealed over 7500 newspaper articles reporting on aspects of the cg2018 during april 2018 goldoc implemented a comprehensive approach towards the promotion of human rights which aligned to the cgf constitution key issues included cultural awareness accessibility inclusivity and gender equality humanity equality and destiny were showcased through goldocs commitment to ensure the parasports program was extensive and integrated building on the success of the inclusive 2002 manchester commonwealth games cg2018 expanded the parasport program by hosting approximately 300 parasport athletes across 38 medal events in seven sports a responsibility towards fairness and nondiscrimination was exhibited through goldocs commitment towards inclusivity and safety for lesbian gay bisexual transgender and intersex individuals demonstrating best practice initiatives for lgbti athletes volunteers and spectators through collaboration with goldoc and the local lgbti community several engagement activities facilitated a safe and inclusive environment including the provision of a pride house the athletes utilising a realtime approach we examined representational media for newsworthy articles that aligned to the core values articulated by the commonwealth games constitution humanity equality and destiny there were five prominent human rights stories appearing in news media during the cg2018 the lgbti community and inclusivity disability and inclusivity indigenous rightsprotests gender equality and homelessness all social cause issues were examined closely to identify connections and communication flows between representational media and the athletes presentational media athletes identified as part of the social cause narrative were delimited to two tom daley advocating for the lgbti community and kurt fearnley ao a disability advocate the social cause narrative involved a twoway flow between the athletes who crafted their connection to and support for the cause via selfpresentation through social media and this was amplified by traditional and new media who shared or repurposed athlete posts as such this demonstrated intercommunication whereby traditional media drew from presentational media constructed by the athletes and conversely the athletes repurposed news items created about themselves or their sociopolitical cause representations of intercommunication whereby social media posts generated by athletes were repurposed in traditional media will be discussed for each athlete pre during and postcg2018 twitter and instagram were the two dominant platforms used by the athletes table 1 during cg2018 daley utilised instagram twitter facebook and youtube twitter was the platform where the greatest intercommunication occurred whereby daley utilised his posts to highlight inclusivity and the lgbti community and the current status of homosexuality within some commonwealth nations a message exposing current inequality and discrimination experienced by the lgbti community in some nations emerged from the peter tatchell foundation daley retweeted and personalised this tweet through his personal social media and subsequently leveraged this during representational media interviews figure 1 screenshot ptf tweet the ptf retweet was shared 155 times and liked by 863 people however the lgbti message achieved greater prominence after daley won gold in the synchronised diving event daley personalised the original ptf message adding how lucky he felt to be able to compete without worry the use of a rainbow emoji signifies a connection to the lgbti community further reinforces daleys connection to the issue also seized the opportunity to promote their message of inclusivity tweeting a photo of a lgbti liaison officer with daley inclusion in the narrative of these two external organisations illustrates daleys perceived prestige upon the conclusion of gc2018 daley posted another four causerelated retweets in two posts daley enhanced the visibility of a realtime movement occurring in the united kingdom and directly linked the role of the commonwealth to human rights daley reposted two messages drawing attention to an lgbt protest in london one by the ptf the other by entertainment celebrity stephen fry daley leveraged his celebrity athlete status to further the discussion with british politician boris johnson a bbc news report was shared via his twitter feed featuring johnson who had promised to build on daleys recent advocacy daley shared a second media article where he discussed his message on the bbcs the andrew marr show justifying the timing of his protest daley indicated that as an openly lgbti athlete he had an opportunity to share his personal story and speak with lgbti movement leaders from other nations to encourage positive change through these two examples daley demonstrates a blend of front stage and backstage performances according to hulls definitions through interviews with representational media daley shares personal behindthescenes insights that can be classified as backstage however by reposting the interviews this represents front stage through sharing his personal story daley builds connections with the cause which enhances his message daleys sense of duty surrounding this cause was surrounded by risk his protest messaging was opposed by several participating commonwealth nations and his next sporting competition was in russia with russia banning lgbt propaganda by law advocating for inclusivity would be considered a major risk in 2014 daley had deemed competing in russia unsafe but he was determined to compete in the may 2018 diving world series daley participated and used subtle messaging by wearing a rainbow pin badge on the medal podium thus being seen as an out and proud gay man in russia amidst this countrys antigay laws the messaging was captured through representational media with the reproduction of daleys instagram content this example highlighted the fluidity of content between representational and presentational content thus illustrating a further expansion of intercommunication in addition this acknowledges daleys agency as he acted as a communication intermediary for the sociopolitical cause daleys articulation of the socialpolitical message during april 2018 drew predominantly from the ptf message intercommunication was more prominent between the networks daley had established and linked directly to his personal social media as an extension of the concept of intercommunication there were communication flows between daleys personal posts and media platforms of other organisations particularly with the ptf and the bbc based on the ptf retweets during the cg2018 there was evidence to suggest daley was aware of his capacity to influence the social cause narrative additionally external organisations leveraged daleys authenticity and success further amplifying the lgbti message and building his reputation persona analysis kurt fearnley ao fearnleys visibility was enhanced during april 2018 across australian media as he was selected as an official games ambassador as one of only five athletes selected as an ambassador fearnley helped promote cg2018 inclusivity appearing in promotional material and was part of the queens baton relay this prestigious representation acknowledges fearnleys value and agency in a similar precelebratory style to daley fearnley tweeted to encourage followers to support the cg2018 and acknowledged the inclusivity that would be shown to athletes with a disability fearnley contributed a prominent narrative through athletesvoice positioning disability as an important issue for the cg2018 athletesvoice provides an alternate platform for athletes to narrate their own realtime news fearnley connected fans to his athletesvoice contribution through twitter fearnley used his own successful sporting performance as an entry point to alert audiences for the need to be inclusive building support for people with a disability fearnley shared personal stories embraced humour team camaraderie and celebratory pictures with friends and family thus providing examples of personal behindthescenes insights twitter was fearnleys main communication platform during cg2018 over 70 of fearnleys 46 tweetsretweets represented backstage presentation fearnleys final event and subsequent success occurred on the last day of the cg2018 with the announcement that he would be the australian flag bearer during the closing ceremony media attention shifted towards the broadcasters who were criticised for not televising the athletes stadium parade as per previous mses fans followers and commentators felt deprived of witnessing fearnleys moment carrying the nations flag on behalf of ablebodied and paraathletes signified the prestige fearnley had accumulated notably fearnley used twitter and a connection to a second article in athletesvoice to reframe the narrative and remind followers of the inclusivity of the cg2018 in a very real sense fearnleys narrative constructs a persona that heightens awareness of disability to a wider public via broadcast media and the games administration itself this represents fearnleys wider visibility and extended reach that he had generated through his authentic representation during the cg2018 as the cg2018 concluded fearnley adopted a stronger presence in the causerelated space and shifted the narrative towards the larger disability discussion in australia by sharing an abc interview via his twitter account this is an example of the intercommunicative strategy through its increasing presentational prestige through the agency of selective sharing the timing may have deliberately avoided the restraints on raising sociopolitical issues but may also have been a leveraging opportunity given his athletic success and that of the cg2018 fearnley selfbranded himself an advocate raised further awareness of the limited funding for people with a disability and sought to acknowledge various forms of disability in society his work was recognised in june 2018 with an officer of the order of australia for distinguished service to people with a disability as a supporter of and fundraiser for indigenous athletics and charitable organisations and as a paralympic athlete fearnleys social media communication contained personalised and positive imagery and messages to support parasport yet it also provided a connection to traditional media which facilitated more extensive conversations and provided a more comprehensive platform to advocate for disability twitter was the main social media platform used by fearnley of the five facebook posts two provided links to athletesvoice which demonstrated intercommunication and allowed fearnley to remain clear with his messaging surrounding disability advocacy selfpresentation and the social cause narrative cg2018 provided an opportunity to demonstrate how two athletes with perceived high value because of their past success in their sports and their associated visibility across media and cultures strategically leveraged their appeal to convey sociopolitical messages within a constrained environment overall daley and fearnley provided evidential support to agyemangs athlete citizenship definition as they each took an approach to channel their influence to create a positive impact on society without breaching the cgf constitution bylaws both athletes have sought to create representations and construction of the self by sharing controlled details about their private lives although carefully curated the details revealed via their social media accounts have helped both athletes build credibility and demonstrate authority when advocating for important societal issues in doing so they both demonstrated a strategic public alignment to issues pertinent to their personal lives the genuine relationship between the athlete and the social cause is reinforced by the history of the athlete as such this supports agyemangs discussion on athlete citizenship whereby stakeholders view and accept congruency the need for audiences to see athlete behaviour as congruent with expectations links also to goffman in addition this extends hutchins and rowes discussion regarding the use of social media at mses and begins to address cunningham and regans question as to whether athletes are willing to advocate for social change daley and fearnley shifted the gaze of fans followers and media coverage from their own performance towards sociopolitical causes during a time of heightened media visibility using their own narratives an element in their identity moves back and forth from traditional media to social media this research expands on previous notions of intercommunication by recognising a complex form of mediatisation through blending personal and professional persona and fluidity between presentational and representational media and exemplary of how mass selfcommunication reforms traditional legacy medias vertical power towards certain political ends as such the athletes use of social media provided a mechanism for their personalised content to move through layers of media and communication respond and intersect with various stakeholders who are themselves drawing meaning making connections and engaging with emerging forms of public activism intercommunication as defined here intersects or traverses a range of media provides connections and expands narratives and engages collective publics it is important to further identify the collective dimension of persona that shapes these athletes public identities each of their personas by the very definition of persona is already working and engaged in a collective space and thereby identifies the core audience that is already perceived as connected to and in some way aligned to the persona it is through the collective that we can identify that the athlete persona is not audience or nationspecific as demonstrated by fearnley and daley the athlete persona could push other national cultures to respond to the needs of their particular causecommunities further studies in this area could explore how celebrity athlete selfpresentation is transferred into other mses that are located in destinations with distinctly different cultures i for example where homosexuality is still criminalised recognising the limitations of this research suggests the need to examine how activism through persona may be constrained by gender ethnicity or representation of marginalised communities further research could also examine the interpretation of messages by diverse audiences and in particular examining sentiment and how the social issue is framed by followers conclusion mses provide platforms for athletes with a strong desire to exhibit citizenship to raise awareness of their cause however they must navigate athlete agreements and policies the visibility of an mse presents a timely opportunity to further social or political discussions and yet the rules at play call for a strategic approach intercommunication is providing complementary alternate and shifting platforms that may assist forms of athlete activism to advance important social change as a form of soft activism what we have identified is an interesting change in value that augments athlete authenticity whilst representing a cause in its movement between a personal social media and a much wider legacy media platform while only two athletes at the gc2018 were observed clearly integrating social cause narratives through intercommunication they demonstrated the unique position athletes can assume as athletecitizen journalists as intermediaries and celebrities they can leverage their influence and reach further contributing to mcgillivrays discussion of transforming accelerating and integrating alternative narratives at mses followers see the constant depiction of the athletes selfpresentation which by the very nature of their everyday lives display and document the barriers that they encounter presentational media and the ability to leverage already established value reputation and prestige have all contributed to a narrative that peaked organically at the cg2018 athletic success and meaningful personal narratives attract representational media which are subsequently interwoven back into personal narratives and thereby leveraging a greater platform building on the previous work of castells and frandsen these athletes are moving through different networks and forms of presentation as they build a strategic persona around citizenship athletes like daley and fearnley with authentic alignment to a cause shared through social media over a period of time may be in a stronger political position to advocate without risking their sporting careers their differentiated agency from their nations sporting bodies and their rules of etiquette had been built through what could be described as a relatively independent online identity agency that employs a shifted construction of public identity the personas these particular athletes have cultivated online with their different construction of publics and collectives reformation of their mediatisation through their individually curated social media platforms and an integrated performative dimension that is both linked to and transcends their athletic achievementsvisibility allow them to develop a nuanced politically inflected public and shared identity that redefines their cultural value agency reputation and prestige this active crosscultivation across media and social media forms of representation and presentation allowed these particular athletes to advance a sophisticated individualised politically and causerelated bespoke athlete persona during and after the cg2018 end notes i this research was conducted prior to the tokyo 2020 olympic and paralympics games daleys successful performances and his lgbti message at the tokyo 2020 olympic games was captured in global news media fearnley had retired from competition in 2018 but was on the commentary team for the tokyo 2020 paralympic games and continues to advocate for disability as a presenter on several television series and via podcasts fearnley was appointed chairman of the board of the national disability insurance agency in 2022

highly mediated megasporting events provide opportunities for elite athletes to use their prominent status to elicit social change however with expectations and policies in place to regulate behaviour that prevent athletes from making political statements athlete activists face risks an examination of the 2018 commonwealth games highlighted two athletes who used their personal reputation whilst at this highly mediated global sporting event to raise the visibility of societal issues through the lens of persona studies this research examined how these athlete celebrities crafted individualised narratives through internetworked platforms of new and traditional media to demonstrate forms of athlete citizenship this research illustrates how athletes can become cocreators of the social cause narrative demonstrating how valuable athletes can be in amplifying the core values of major sporting events by reinforcing a fluid form of intercommunication

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background despite improvements in child survival in the past four decades an estimated 63 million children under the age of five die each year and more than 40 of these deaths occur in the neonatal period 1 complications related to preterm birth is the leading cause of death among children under five 2 effective implementation at scale of evidencebased interventions to reduce complications of preterm birth and associated neonatal mortality is needed kangaroo mother care is one such evidencebased lifesaving intervention there are four components of kmc including 1 early continuous and prolonged skintoskin contact between infant and caregiver 2 exclusive breastfeeding 3 early discharge from hospital and 4 adequate support for caregiver and infant at home 34 in addition to providing thermal control kmc is associated with a 36 reduced risk of neonatal mortality among low birth weight newborns compared to conventional care as well as a significantly reduced risk of sepsis hypoglycemia and hypothermia 5 despite the strong evidence regarding the improved health outcomes among preterm or low birth weight infants receiving kmc including a recent recommendation by the world health organization that kmc should be routine care for newborns weighing less than 2000 g 6 this intervention has never been fully integrated into health systems around the world a previous systematic review identified barriers to health system adoption of kmc and noted that families play an important role in kmc adoption 7 further the review noted that family interactions with the health system were critical to kmc adoption caregivers are key implementers and beneficiaries of kmc we explore the barriers and enablers of kmc implementation from the caregiver perspective in greater detail in order to understand the role of families in the adoption diffusion and assimilation of kmc we build on a conceptual framework for integration of targeted health interventions into health systems 78 this framework promotes analysis in five areas including definition of the problem definition and attributes such as the relative advantage and complexity of the intervention package the adoption system including key actors their interest values and the power dynamics between them health system characteristics and the broad context including demographic economic and cultural factors using this framework we analyzed how caregivers perceive the risks and benefits of the intervention as well as their values and interests surrounding kmc specifically we identified barriers and enablers of implementation and scale up of kangaroo mother care based on the first systematic review on kmc implementation and uptake from the caregiver perspective methods in order to identify research studies for this review we searched pubmed embase web of science scopus aim lilacs imemr imsear and wprim search terms included kangaroo mother care or kangaroo care or skin to skin care studies published between january 1 1960 and august 19 2015 were included we also reviewed the references of published systematic reviews searched unpublished programmatic reports and requested data from the saving newborn lives program at save the children we excluded studies if they did not include human subjects and primary data collection to be eligible for inclusion into the review published work had to include information about barriers to or enablers of successful implementation of kmc from the family perspective based on the experience of caregivers and health providers who had implemented kmc two independent reviewers used a standardized data abstraction form to assess eligibility and abstract data from each article if the case reviewers did not agree about the inclusion of a study a third reviewer broke the tie each eligible study was assessed for the potential risk of bias in five domains including selection bias appropriateness of data collection appropriateness of data analysis generalizability and consideration of ethics 9 through several iterations of manual annotation and indexing two researchers coded themes perspectives and experiences using nvivo software abstracted data were linked to the conceptual framework using a deductive approach and themes were identified within each of the five framework areas narratives were constructed around each major theme and we used quotes to summarize perspectives from each study the major themes and narratives were used to develop matrices where we defined important concepts the range and nature of each theme and the relationship between themes we used this metasynthesis approach based on our objective of understanding caregiver perception and our hope that the results can inform policy and enhance our understanding of how to implement this complex intervention within health systems 10 results we identified a total of 2875 abstracts there were 1360 abstracts after removing duplicates 716 were excluded after title and abstract review and the full text was reviewed for 644 a total of 98 were included in the analysis all studies were considered of sufficient quality to include in the analysis the majority of publications were published within the past 5 years had a sample size less than 50 and recruited participants from health facilities onethird of the studies were conducted in the americas 265 in africa 163 in europe and the remaining in southeast asia eastern mediterranean western pacific or in multiple regions more than half of the studies were conducted in an area with a neonatal mortality rate 15 deaths per 1000 live births after analyzing the data collected from the family perspective we confirmed that caregivers are an essential component of the kmc adoption system as they are the primary decisionmakers and are responsible for infant feeding and skintoskin contact we identified four themes surrounding the interaction between caregivers and the kmc intervention buy in and bonding social support time and medical concerns furthermore we identified barriers and enablers of kmc adoption by families within the context of the health system and the broader social context these themes are summarized in table 2 barriers and enablers for caregiver adoption of kmc caregiver buyin and bonding buyin and bonding referred to the acceptance of kmc belief in the benefits of kmc to mothers and preterm infants and reported perceptions of bonding between mother and infant uptake of kmc was impaired by limited buyin to kmc by mothers fathers and families for example my experience told me this kmc was not right…so before caesarean section i was worried about it 11 mothers were less likely to accept kmc if healthcare workers could not clearly explain the benefits of kmc parents reported that they were simply told to perform kmc without explanation why or how to do so and the feeling that kmc was forced upon them hindered buyin from caregivers 12 another barrier to parental buyin occurred when caregivers perceived that their newborn did not enjoy kmc in some areas due to the hot climate parents observed their infant became irritable or stinky during ssc 13 less frequently caregivers mentioned discomfort at not being able to see their newborn during kmc 14 another barrier was lack of bonding by mothers with their preterm infants 11 in some cases lack of bonding with the infant was due to fear stigma shame guilt or anxiety about having a preterm infant 1516 and some did not want to keep the baby at all 17 for example i wished that i had had a miscarriage instead of delivering this preterm it would fig 1 systematic review flow chart be better i never thought that this baby would survive i thought that it would die any time 17 however positive perceptions among mothers fathers and families regarding the potential benefits of the intervention promoted kmc uptake caregivers who successfully implemented kmc perceived that performing kmc calmed their baby 18 19 20 21 22 these mothers observed their newborns sleeping longer during skintoskin contact infants were described as less anxious more restful more willing to breastfeed and happier to be in ssc position than in an incubator 1823 kmc was also perceived as a healing mechanism for the parents it helped mothers and fathers recover emotionally and physically as well as create a family bond 24 kmc made mothers feel useful for example every time i hold her the monitorseverythingdid better her oxygen sats did better i really think i helped her…and think that the human contact and…hearing my heart and everything i really think that helped her 19 some fathers reported feeling needed and enjoyed participating in the early care of their newborn further families using kmc described the time during and after kmc as relaxed calm happy natural instinctive and safe 25 26 27 28 29 30 parents reported that the bonding associated with kmc felt connected familiarizing comforting and logical mothers preferred kmc to traditional incubators because they felt closer to their babies and it put them at ease 31 social support for caregivers social support referred to the perception and reality that one has assistance from other people to perform kmc while practicing kmc mothers and fathers did not feel supported by their families or communities 1525 mothers experienced a lack of support from healthcare workers some hospital staff were resistant to family participation in caring for the baby while in the hospital 32 healthcare workers were occasionally considered to be loud and uncaring by parents 3334 additionally kmc was impaired when parents perceived that hcws did not respect family privacy 35 fathers reported lack of support from society and frequently voiced discomfort about performing kmc because of societal norms as many fathers felt that childcare should be the role of the mother 1536 older generations mothersinlaw and grandmothers in particular did not find kmc to be an appropriate method to care for newborns 37 in contrast kmc uptake was promoted by societal acceptance of paternal participation in childcare by family and community acceptance of kmc and by the presence of engaged hcws 3839 in societies where gender roles were more equal there were fewer barriers to fathers performing kmc 3940 paternal involvement played a large role in kmc uptakeeither by division of labor or by helping the mother feel comfortable 41 mothers were grateful to have someone help them during kmc such as grandmothers and sisters who could take care of housework and help with the newborn within the maternity ward peer support from other mothers who shared their kmc experiences also promoted acceptance 3642 additionally the presence of welltrained nurses reduced maternal apprehension about practicing kmc and handling their newborn facilitating the implementation of kmc 43 caregiver time for kmc adoption kmc guidelines recommend continuous ssc for as long as possible until the newborn reaches a certain weight certain age or no longer tolerates it 4 the lengthy time needed to provide kmc was a barrier for caregivers kmc was difficult to perform at long intervals if the mother was depressed lonely or recently had a csection 44 many mothers found kmc performance at home to be a burden due to other responsibilities at home or work for example one mother said obviously ive got a husband and another child at home and obviously have to cook…you have to clean and do a lot of other things besides looking after yourself and the baby 42 another mother noted although i am very satisfied with the kmc method it made me feel divided as i was unable to be close to my other child this must be even more complicated for those whose infant needs a longer period of hospital stay 27 another difficulty was commuting between home and kmc wards 1718273639424546 thus the ability to practice kmc at home rather than in a facility promoted the uptake of kmc by allowing caregivers to attend to other chores 47 parents noted that unlimited visitation hours enabled adoption of kmc furthermore facility staff felt as though parents were less interfering when they were allowed unhindered access to their babies 48 caregiver medical concerns medical concerns including the clinical condition of the mother or newborn may also be a barrier that prevents kmc uptake for examples mothers in ghana found ssc problematic because they fear that by touching the umbilical cord of the newborn it would divide into two and cause pain bleeding or sickness 49 clinical consequences of kmc for mothers included fatigue depression and postpartum pain some mothers experienced discomfort sleeping upright with a newborn in kmc position 1339 postpartum pain was considered a hindrance to ssc especially after a csection 29394950 however women practicing kmc thought it helped them to recover from postpartum depression 51 mothers seemed to be satisfied with the method and felt that it helped relieve stress 3152 health system barriers and enablers for caregiver adoption of kmc adoption of kmc by caregivers generally begins in the context of the health system and caregivers may interact with any of the core components of a health system we found that financing and service delivery were aspects of the health system that influenced caregiver adoption of kmc financing first in the case that the newborn remained in the hospital after the mother was discharged lack of money for transportation and the distance to the hospital were often reported as the biggest challenges to kmc implementation these were also barriers to returning to the health facility for follow up after both mother and infant were discharged but continuing kmc 53 54 55 56 in an evaluation of a kangaroo care inpatient ward of a tertiary hospital in malawi 10 mothers whose children died reported the distance to the health facility or lack of transport money as the reason they did not go the hospital when something was wrong with their newborn similarly nearly 40 of mothers reported lack of transport money as the reason they did not go the hospital for their follow up clinic appointments 56 in kuala lumpur malaysia poor public transportation and the difficulty of returning to the hospital after restarting work were the most frequently mentioned challenges to performing skintoskin contact on a daily basis while the newborn was still hospitalized 55 on the other hand free medical service enabled parents to stay at the clinic longer as needed also parents in harare zimbabwe believed that kmc decreased the cost of hospital bills and assumed that it was a cheaper option than conventional incubator care or a prolonged hospital stay 15 service delivery for caregivers lack of privacy and kmc resources at facilities presented obstacles to kmc adoption structurally there was a lack of private space for mothers to perform kmc and a lack of space for mothers to remain in the hospital with the newborn 5758 mothers felt uncomfortable and exposed as staff continued to come in and out during kmc 25 for example there were always people around it is harder when there are people other people coming in and out private rooms will help 50 another mother reported from seven in the morning until five in the afternoon people came in all the time people came in to clean the room clean the bathroom to check on me and someone else to check on the baby every fifteen minutes someone different would come in i could never relax it was exhausting it was stressful i couldnt relax 50 lack of resources at facilities was also a barrier to adoption at one facility materials donated for kmc were put into vip units rather than the kmc ward 54 however the provision of private spaces a quiet atmosphere and dedicated resources promoted the acceptance and uptake of kmc 34 privacy screens or private rooms allowed the family separation from hospital staff and other patients and offered a quieter atmosphere for the mothers to conduct kmc 59 social and cultural barriers and enablers for caregiver adoption of kmc we hypothesized that the broad social context influence caregiver adoption of kmc for example surveys from 15 lowincome countries noted that health care professionals often found that kmc was thought of as substandard or as the poor mans alternative 36 also caregiver adherence to traditional newborn practices was reported as a barrier to kmc 55 traditional early bathing behavior was seen as having numerous benefits and was identified as an ingrained behavior by studies conducted in ghana and bangladesh 1760 one traditional birth attendant noted the child needs to be bathed immediately in order to shape the head because whenever a child is delivered the head is very flat so you need to sharpen it to make it round 60 a mother who had recently delivered noted that babies are normally bathed shortly after birth because it will help them feel clean and healthy 60 other traditional practices such as sleeping by a lamp and smearing the baby with oil make uptake of kmc more difficult in reports from ghana and malawi where carrying the baby on the back was common it seemed strange to place the baby on the front as instructed by kmc one woman explained the back is stronger than the front and better for carrying 49 in some contexts it was considered unclean to have the mother carry the baby on her chest without a diaper 36 stigma surrounding having a preterm infant can be severe and can act as a barrier to continued practice of kmc different approaches to gender roles the role of parents in childcare the role of men in the household and the roles of other family members also influenced kmc uptake 153236 for example some fathers reported feeling uncomfortable practicing kmc in public learning how to perform kmc while other people were present or being scrutinized by nurses 4261 additionally in some cases mothers and traditional birth attendants reported feeling uncomfortable with the father performing their duties 25 discussion kangaroo mother care is a complex intervention as defined in our conceptual framework because user engagement is high and caregiver behavior dominates our definition of successful implementation of the intervention 8 thus scaleup of this intervention around the world relies heavily on enabling caregivers to successfully adopt kmc we found that buyin and bonding social support time and medical concerns were major themes defining the interaction between families and the kmc intervention furthermore we identified financing and service delivery as barriers of kmc adoption within the context of the health system additionally we identified social and cultural norms that played an important role in the adoption of kmc efforts to implement and scale up kmc must work to ensure a positive experience for caregivers for example the benefits of kmc to the newborn and caregivers must be clearly explained to everyone involved one approach is to ensure healthcare workers present information about kmc in a standardized manner to caregivers and extended families with attention paid to their concerns additionally testimonials about the effectiveness of kmc could be given by caregivers who have successfully cared for a preterm or low birthweight baby in the past such an approach is recommended in the maternal and child health integrated program kmc guide 62 demonstrations and supervised practice can enhance caregiver confidence approaches to enhance newborncaregiver bonding are needed for example programs might create a song about kmc to be sung to the baby or healthcare workers could demonstrate the change in infant temperature after a period of skin to skin contact 63 despite efforts and ideas from programs and practitioners about how to create a positive kmc experience for caregivers there is limited evidence about which approaches are effective we found that social support can enhance the uptake and duration of kmc to enhance social support and promote positive attitudes about kmc the maternal and child health integrated program kmc guide recommends that programs undertake sensitization to kmc at the national health facility and community levels at the communitylevel recommended activities include celebrations for the graduation of a baby from kmc or discussions about kmc through radio or other public forums 62 similarly a program in malawi asked respected grandparents to promote kmc and newborn care behavior in the agogo program the ekwenedni church of central africa presbyterian mission hospital trained nearly 4000 grandparents subsequently grandparents provided individual and group counseling in their respective villages using drama song and poems to share key messages an evaluation of the program concluded that grandparents were successful in promoting behavior change surrounding maternal and newborn care 64 encouraging family members to provide support by assisting mothers with other household responsibilities or coaching mothers how to ask for this support may also increase duration of kmc after hospital discharge currently there is limited evidence about the effectiveness of such sensitization efforts interactions between healthcare workers and families may either encourage or discourage caregiver adoption of kmc this is consistent with research which demonstrated that interpersonal healthcare worker behavior is a significant contributor to patient satisfaction with maternal health services which subsequently influences service utilization 65 66 67 healthcare workers and facilities can be supportive in their words and actions by providing privacy for the family as they learn kmc and by ensuring unlimited visitation hours so that kmc can happen without time or schedule constraints health system concerns regarding financing travel food lodging etc may be partially alleviated by ensuring early discharge of mother and infant from the hospital additionally kmc programs may consider ways to reduce hospital charges or provide transportation vouchers for families of infants with longerthanaverage stays for example some programs in colombia maintain social funds to provide financial support to families who must travel to a health facility in the period of close follow up after the newborn is discharged from the hospital automated cash transfers using cell phone technology might be a method to reduce financial barriers transportation and time costs may also be addressed by offering home visits by community health workers for infant follow up further studies are needed to generate evidence regarding the feasibility and effectiveness of such an approach it is important to acknowledge that mothers fathers and families are adopting kmc within a broader social context several studies specifically noted that there may be stigma associated with having a preterm infant or around male involvement in child care which present barriers to kmc uptake divisions of labor and space by gender have been found to be barriers to male participation in newborn care in general however as dumbaugh et al note inclusion of men in newborn care must be done in a way that is empowering for women 68 to address the reluctance of fathers to engage in childcare fathers successfully engaging in ssc might become peermentors or demonstrators for other families the intervention name kangaroo mother care might also be changed so that it does not directly imply the behavior is performed only by the mother additional research about how to encourage paternal involvement and reduce stigma surrounding these childcare strategies must be a part of kmc scale up in any context strengths limitations the primary strength of this research is that it draws on the rich body of qualitative research that can help policymakers and public health professionals to understand the complex context in which this intervention is implemented however our conclusions are limited by the existing body of evidence there has been less research conducted in southeast asia and subsaharan africa where kmc has the potential make the greatest impact furthermore nearly half of the studies were conducted in urban settings with low neonatal mortality additional research is needed in the places where kmc has the potential for the highest impact and should be geared towards understanding the needs of caregivers of preterm and low birthweight infants future research should also investigate ways to generate demand for kmc services conclusion we found that lack of buyin poor social support lack of time at the hospital or at home and medical concerns about the mother or infant were barriers to caregiver adoption of kmc furthermore we identified barriers and enablers of kmc adoption by families within the context of the health system and the broader social context future efforts to integrate kmc into local regional or national health systems must make efforts to identify and reduce barriers and promote enablers for successful caregiver adoption of kmc ultimately kmc programs must ensure that the kmc experience is a valuable and positive experience from the caregiver perspective abbreviations kmc kangaroo mother care ssc skintoskin contact availability of data and materials not applicable authors contributions gc conceptualized and designed the review ib sc reviewed and abstracted data es gc drafted the manuscript all authors edited and reviewed the manuscript all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests consent for publication not applicable ethics approval and consent to participate not applicable

background despite improvements in child survival in the past four decades an estimated 63 million children under the age of five die each year and more than 40 of these deaths occur in the neonatal period interventions to reduce neonatal mortality are needed kangaroo mother care kmc is one such lifesaving intervention however it has not yet been fully integrated into health systems around the world utilizing a conceptual framework for integration of targeted health interventions into health systems we hypothesize that caregivers play a critical role in the adoption diffusion and assimilation of kmc the objective of this research was to identify barriers and enablers of implementation and scale up of kmc from caregivers perspective methods we searched pubmed embase web of science scopus and who regional databases using search terms kangaroo mother care or kangaroo care or skin to skin care studies published between january 1 1960 and august 19 2015 were included to be eligible published work had to be based on primary data collection regarding barriers or enablers of kmc implementation from the family perspective abstracted data were linked to the conceptual framework using a deductive approach and themes were identified within each of the five framework areas using nvivo software results we identified a total of 2875 abstracts after removing duplicates and ineligible studies 98 were included in the analysis the majority of publications were published within the past 5 years had a sample size less than 50 and recruited participants from health facilities approximately onethird of the studies were conducted in the americas and 265 were conducted in africa we identified four themes surrounding the interaction between families and the kmc intervention buy in and bonding ie benefits of kmc to mothers and infants and perceptions of bonding between mother and infant social support ie assistance from other people to perform kmc sufficient time to perform kmc and medical concerns about mother or newborn health furthermore we identified barriers and enablers of kmc adoption by caregivers within the context of the health system regarding financing and service delivery embedded within the broad social context barriers to kmc adoption by caregivers included adherence to traditional newborn practices stigma surrounding having a preterm infant and gender roles regarding childcareefforts to scale up and integrate kmc into health systems must reduce barriers in order to promote the uptake of the intervention by caregivers

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introduction in canada approximately 62050 people were living with hiv in 2018 with an incidence of 2242 new cases 1 hiv prevalence has been increasing in canada due to a combination of increased incidence and lengthened life expectancy due to the advent of antiretroviral therapy 23 as individuals are living longer hiv is considered a chronic condition 4 characterized by health consequences related to hiv aging and other health conditions such as mental health issues 5 cardiovascular disease 6 opportunistic infections 7 and musculoskeletal disorders 8 these healthrelated consequences can be defined as disability including physical cognitive mental and emotional symptoms and impairments which add challenges to carrying out daily activities social inclusion and worrying about future health and uncertainty 2 9 10 11 physical activity and exercise are an effective rehabilitation strategy for addressing disability and improving health outcomes among plwh 12 pa is defined as incorporating any bodily movements which creates energy expenditure including conditioning exercises household chores engagement in sports and other activities which use movement whereas exercise is defined as a subset of pa which is planned structured and repetitive with the goal of improvement or maintenance of physical fitness 13 engagement in pa of moderate to vigorous intensity is correlated with better health outcomes in the general population 14 systematic review evidence indicates that engagement in exercise at least 3 times per week for at least 4 weeks is safe and can lead to benefits in cardiorespiratory strength weight and body composition and quality of life outcomes among plwh 1516 the world health organization recommends adults aged 1864 year including those with chronic conditions or disability should undertake at least 150300 min of moderateintensity aerobic pa or at least 75150 min of vigorousintensity aerobic pa or an equivalent combination of moderateintensity and vigorousintensity activity throughout the week with at least 2 days of muscle strengthening activities to obtain benefits of engaging in pa and exercise 17 for older adults the guidelines include additional emphasis on enhancing balance and preventing falls 17 despite recommendations and documented benefits engagement in pa and exercise varies among plwh systematic review evidence suggests that rates of physical inactivity among plwh ranged from 1973 indicating a range of exercise uptake among the population 18 the role of social determinants of health on engagement in pa and exercise among plwh is emerging social determinants of health are defined as conditions with which people are born grow live work and age that shape their level of power income and other determinants of life 19 these determinants can play a crucial role in creating health inequities which are avoidable differences in our health status 19 among plwh determinants such as cost associated with exercise health status and disability along with neighbourhood and vulnerability to stigma influenced engagement in pa and exercise among plwh 2021 other barriers to exercise included parenting and employment responsibilities attributed to relationships plwh have with gender roles education level and socioeconomic status in a review of plwh the role of social support and socioeconomic status influenced ability and level of engagement in exercise 22 although previous studies have examined the role of specific independent sdoh on engagement in pa and exercise a comprehensive review of the collective role of sdoh on exercise in the context of hiv is unknown our aim was to characterize the literature pertaining to the role of sdoh on engagement in pa or exercise among adults living with hiv materials and methods we conducted a scoping review to investigate what is known and not known about sdoh and engagement in pa or exercise among adults living with hiv conceptual foundation we used the public health agency of canada sdoh framework as a conceptual foundation for our review this framework encompasses 12 determinants income and social status employment and working conditions education and literacy childhood experiences physical environments social supports and coping skills healthy behaviours access to health services biology and genetic endowment gender culture and raceracism 23 we included any articles that referenced pa or exercise regardless of definition that reported any form of bodily movement produced by skeletal muscles that requires energy expenditure 13 we used the prismascr 24 joanna briggs institute manual for evidence synthesis 25 and arksey and omalley framework supplemented by levac colquhoun obrien to inform the methodology of this review 2627 step 1 identifying the research question we set out to answer the following research question what is the nature and extent of evidence related to the relationship of sdoh on engagement in pa or exercise among adults living with hiv we defined nature of evidence as the type of literature on the relationships between sdoh and in engagement of pa or exercise among adults living with hiv we defined extent of evidence as the amount of literature on the relationships between sdoh and engagement in pa or exercise and their role with adults living with hiv step 2 identifying relevant studies we searched medline cinahl embase psycinfo sportdiscus and web of science to identify research studies pertaining to sdoh pa or exercise and hiv we used a two concept medline search on pa or exercise and hiv using both a combination of keywords and mesh headings and validated search filter with modifications 28 supplementary search terms were added to capture research relevant to the phac framework on childhood experiences healthy behaviors biology and genetic endowment we adapted the final medline search for syntax and subject headings for the other databases see supplementary file s2 for the medline search strategy we included articles that addressed pa or exercise adults living with hiv and addressed at least one sdoh as conceptualized by the phac sdoh framework we included articles published from 1996 and onwards and were published in english language we limited our search to 1996 onwards as this is when highly active antiretroviral therapy emerged resulting in prolonged survival of plwh 29 step 3 study selection we imported citations yielded from the search into endnote referencing software version x9 30 and then into distillersr software version 235 31 to facilitate the process for screening citations and abstracts for study selection we reviewed studies for inclusion in three stages title review abstract review and fulltext review title review two reviewers independently screened each title for the ability to address hiv pa or exercise and sdoh by answering the following question is the focus of the article to examine explore measure the associations of sdoh with pa andor exercise with yes no and unsure options if any two of three components were included in the title reviewers responded yes the article was excluded if both reviewers responded no to the abovementioned question if a reviewer responded unsure the article was included in the subsequent stage for abstract review abstract review the same two reviewers piloted the study selection criteria with five initial articles by independently screening five abstracts and answering the following questions based on the inclusion criteria 1 does the article include adults living with hiv 2 does this article include pa andor exercise 3 was this article published from 1996 and onwards 4 is the primary focus of the article to examine explore measure the associations of the sdoh with pa andor exercise all authors conducted a second abstract piloting process of 10 additional citations the study team met four times to discuss and refine the abstract review process two reviewers independently completed the abstract review if both reviewers responded yes to all of four inclusion questions these articles were included in the full article review if both reviewers responded no to any of the four inclusion questions then the article was excluded if any of the responses were unsure by at least one of the reviewers for an article the article was included in the subsequent stage of fulltext review fulltext review two reviewers independently reviewed full text of articles to determine inclusion we piloted the process with 10 articles involving the four questions above for inclusion all authors met to discuss the findings from the full text review if any uncertainty arose pertaining to article inclusion a third reviewer determined the final inclusion two authors contacted authors if we could not retrieve a fulltext article or if data specific to plwh were not included in the article we refined our study selection criteria to include articles with aims or objectives that directly related to examining the relationship of sdoh on pa or exercise among plwh step 4 charting the data we extracted data from included studies for the following variables title author year of publication study location city and country of lead author study purpose study objectives study design type of article data collection method study participant characteristics types of outcomes measured intervention conceptual framework used sdoh reported in the article authors results and conclusions authors results and conclusion specific to pa and sdoh our reviewer interpretations and additional notes two reviewers extracted the data from included studies using a data charting form on microsoft excel 32 see supplementary file s3 for the operational definitions of concepts extracted from the included articles we piloted the data extraction form in conducted two rounds two reviewers independently extracted data from five included articles using the data extraction form to ensure consistency followed by an additional five articles following each round of the pilot the entire team met to refine the data charting form two reviewers extracted data from the 10 pilot articles using the data extraction form which was reviewed by the team to ensure comprehensiveness and consistency in the data extraction process step 5 collating summarizing and reporting the results we described characteristics of included articles using frequencies and percent for categorical variables and content analytical techniques for text data 25 33 34 35 36 37 38 the research team met four times throughout this step to discuss our synthesis and reporting of results results we yielded 15836 citations from the search strategy from cinhal embase medline web of sciences psycinfo and sportdiscus databases after removing 4754 duplicates this resulted in 11060 citations after screening title and abstracts we retained 89 articles for fulltext review of the 89 fulltext articles reviewed 41 articles were included in the review see figure 1 for the prisma diagram see supplementary file s4 for the citations of excluded studies classified as indirectly related to sdoh the prisma diagram see supplementary file s4 for the citations of excluded studies classified as indirectly related to sdoh characteristics of included studies table 1 describes the characteristics of the included articles among the 41 included articles 35 were research studies involving primary data collection 21 one was a secondary analysis 68 three were systematic reviews 69 70 71 and two were narrative reviews 2272 characteristics of included studies table 1 describes the characteristics of the included articles among the 41 included articles 35 were research studies involving primary data collection 21 one was a secondary analysis 68 three were systematic reviews 69 70 71 and two were narrative reviews 2272 adherence to exercise was independent of gender in the group of participants who were defined as adherent to exercise there were 5 female and 7 male patients whereas among nonadherent group of participants there were more female than male there was a higher proportion of black african participants living with hiv among the nonadherent group and higher proportion of white british in the adherent group than expected from the overall ethnic distribution in the sample sedentary jobs prevented participants accumulating adequate steps the week was challenging in that i was working shifts and i have to sit on a chair the whole shift when participants were busy at work they were less likely to follow their program tired after i was doing the house work and working in the shop the whole weekend the state of the weather was frequently voiced as a barrier and complaints ranged from the weather being too hot cold or raining a lot i am fine the weather is the problem a social environmental barrier was the incidences of domestic abuse and crime that influenced participants livesan important facilitator to pa was the support and motivation received from friends and family semi structured interviews exercise readiness described as a dynamic spectrum ranging from not thinking about exercise to routinely engaging in daily exercise participants described the importance of social support as facilitating readiness to exercise several participants indicated that having someone to exercise with would improve their willingness to engage in exercise some described how an hivspecific exercise program would facilitate their readiness by creating a safe and inclusive environment eliminating the challenges associated with disclosure when describing the conditions that influenced readiness to engage in exercise most participants expressed the importance of accessibility for some a perceived lack of financial accessibility created obstacles to engagement and hindered their readiness to exercise higher educational level was associated with higher physical activity levels in 67 studies gender differences were inconsistently reported ie while six studies indicated men engaged in more physical activity than women another reported the opposite while eight other studies showed no difference between genders while one study reported a higher physical activity levels in the nonwhite population another reported lower levels and four studies reported no associations having a manual labor versus nonmanual labor job and a higher annual income were all in one study significantly associated with a higher physical activity level while only one of two studies found that having a job was associated with more physical activity two of three studies reported on social support as a potential positive correlate to pa women reported exercising an average of 24 h per week and men exercised an average of 35 h per week no differences in the quantity of exercise between men and women except during middle adulthood when walking was removed however this relationship disappeared men did less lowintensity walking than women but this overall difference was not statistically significant men and women exercised at different intensities in both young and middle adulthood the average exercise frequency for women and men was three bouts per week no statistically significant differences in the frequency of exercise between men and women participants living with hiv removing lowintensity walking significantly decreased the average amount and number of bouts of exercise per week for men and women these findings indicate that women living with hiv may have access to more exercise resources than men or that they are more likely to take advantage of resources resulting in higher intensity more balanced exercise patterns not defined men reported engaging in more light and moderate pa compared with women participants walked an average of 402 metres on the 6mwt with expected differences by sex however both men and women achieved similar rates of their sexand agepredicted distance on the 6mwt among women engaging in any vigorous physical activity in the past week there was a 73 increase in achieving their ageand sexpredicted distanced on the 6mwt after controlling for known covariates authors did not observe a similar relationship in men common barriers to exercise were a lack of time expense and safety concerns which were not specific to hiv status concerns of safety often manifested as an explanation for limited outdoor exercise one male participant living with hiv described fear of crime as a primary reason for not exercising outside this sentiment was echoed by others indicating threats to safety as the reasons for not going outdoors to exercise quantitative results suggested a trend toward people living with hiv engaging in less physical activity compared to people without hiv among people living with hiv men performed higher physical activity than women in the following variables median minutes of mvpa in the past week median steps per day and distance on the 6mwt however results were not statistically significant study design among the 35 studies involving primary data collection 23 were quantitative 3435373840424445 48 49 50 51 52 53 54 5759 61 62 63 64 65 66 eight qualitative 2136394147555658 and four mixed method studies 43466067 among the 23 quantitative studies 18 studies were crosssectional 34373840424445 48 49 50 52 53 54 59 62 63 64 66 two cohort studies 3561 two intervention studies 5157 and one was a randomized controlled trial 65 data collection four of the qualitative studies involved focus groups 36395556 and the remaining four involved semi structured interviews for data collection 21414758 quantitative studies used questionnaires clinical records medical examination and different pa measurement tools study location among the 35 studies involving primary data collection study locations included the united states 35363940495556596465 south africa 41 50 51 52 60 uganda 386367 malawi 3453 canada primary purpose of included articles thirtyone of the 41 included articles included a primary purpose to explore the association or relationship of sdoh with pa or exercise in plwh 212236 38 39 40 41 42 43 44 45 47 51 52 53 54 55 56 57 58 59 60 6264 66 67 68 69 70 71 72 whereas 10 articles examined sdoh in the context of other aims 34353746 48 49 50 616365 among these 10 articles four evaluated the association of sdoh with pa or exercise as a secondary aim of the study 46496163 among the three systematic reviews one determined the correlates of pa in plwh by reviewing six studies 71 and the remaining two primary purpose of included articles thirtyone of the 41 included articles included a primary purpose to explore the association or relationship of sdoh with pa or exercise in plwh 212236 38 39 40 41 42 43 44 45 47 51 52 53 54 55 56 57 58 59 60 6264 66 67 68 69 70 71 72 whereas 10 articles examined sdoh in the context of other aims 34353746 48 49 50 616365 among these 10 articles four evaluated the association of sdoh with pa or exercise as a secondary aim of the study 46496163 among the three systematic reviews one determined the correlates of pa in plwh by reviewing six studies 71 and the remaining two systematic reviews investigated the prevalence and predictors of dropout in pa interventions by reviewing 36 studies 69 and evaluated barriers and facilitators of pa participation in plwh by synthesizing 45 studies 70 among the two narrative reviews included in this review their purposes were to discuss the opportunities and challenges of benefiting from different types and effects of pa and to examine the literature on pa social support and socioeconomic status and to generate recommendations for designing and implementing pa interventions with plwh 2272 characteristics of participants in this section we describe characteristics among studies involving primary data collection two studies included the same study population within the same study hence we report characteristics of the sample from one article only 3863 resulting in a total of 34 research studies in this review see table 1 for characteristics of participants in included studies among the 14835 participants in the 34 research studies sample sizes ranged between 8 and 8104 participants the study population were plwh in all but one study where 30 out of 59 participants were hiv positive and the remainder were hiv negative 67 among the 34 studies four included women only 37 435159 and one study included men only 55 of the total sample of participants in the 34 studies 57 were men and 43 were women terminology and definitions of pa and exercise varied across the 35 studies involving primary data collection eighteen studies did not provide a definition of pa or exercise 394346 48 49 50 51 52 55 56 57 58 59 60 61 64 65 66 among the remaining 17 studies 13 referred to the definition of pa and four used a definition of exercise among the 13 studies that referred to the definition of pa 7 followed recommended guidelines of pa by the world health organization which was a total of at least 30 min of moderateintensity aerobic pa per day five or more days a week or three or more times per week for at least 20 min of vigorousintensity aerobic activity 34424445475363 exercise definition varied in four studies 21364154 evidence related to relationship of social determinants of health with physical activity and exercise nine out of 12 sdoh were addressed across the 41 included articles the number of sdoh addressed in each article ranged from one 34373940 43 44 45 49505356 64 65 66 to eight 70 the most common sdoh addressed across included articles was gender followed by social support and coping skills income and social status education and literacy employment and working conditions physical environment healthy behaviors raceracism and culture three sdohs were not addressed in any of the included articles none of the articles utilized a predetermined sdoh framework to report their findings given the heterogeneity of the study aims study design and sdoh addressed across the articles we describe results of the individual articles for each of the sdoh below gender gender was reported among 24 of the 41 articles with mixed results 3435 legend x and grey shaded cell indicates sdoh was represented in the article given the heterogeneity of the study aims study design and sdoh addressed across the articles we describe results of the individual articles for each of the sdoh below gender gender was reported among 24 of the 41 articles with mixed results 34353742 44 45 46 4850 52 53 54 57596162 64 65 66 67 68 69 70 71 several crosssectional studies reported that on average women living with hiv engaged in lower levels of pa than men living with hiv for example chisati et al reported 51 of women participants had low pa levels compared to 22 of men with hiv with less than half of women engaged in high intensity pa compared to men 34 one crosssectional study collected pa data by using the global physical activity questionnaire and found men living with hiv engaged in more pa than women in workrelated transportrelated and leisurerelated pa but especially in workrelated pa 52 additionally another study reported women had higher odds of not adhering to pa recommendations compared with men 162 95 confidence interval 101 to 257 38 muronya et al reported greater physical inactivity among women than men however gender was not statistically associated with pa 53 a crosssectional study found that women living with hiv engaged in less pa than men but only during middle adulthood 64 two cohort studies reported similar findings where men were more physically active than women 3561 one rct aimed to evaluate the 3and 6month effects of an intervention on pa and dietary quality in plwh at high risk of developing cardiovascular diseases and reported women were consistently associated with engaging in less pa compared with men 65 wright et al found that men engaged in more intentional pa but women engaged in more pa related to activities of daily living indicating that the definition of and type of pa was correlated with gender differences 67 one study found a low level of pa among women from low ses with limited time spent in vigorous activities among groups of women from rio di janeiro and maputo with daily light pa higher among women living in rio compared with maputo however data were not compared to pa among men 37 dang et al was the only study to find that women gender was weakly associated with higher pa levels as measured by the international physical activity questionnaire 42 several studies found no significant associations between gender and pa level 445057 two systematic reviews could not conclude whether men or women engaged in more pa due to inconsistent findings among included studies 7071 another systematic review and metaanalysis investigated the prevalence and predictors of treatment dropout in pa interventions in plwh and reported a lower proportion of men participants moderated the higher dropout rates 69 social support and coping skills social support and coping skills and pa among plwh were reported in 15 of the 41 articles 21223638404147495155 58 59 60 6370 fourteen of the 15 studies found that social support was an important facilitator of pa among plwh gray et al conducted a qualitative study with active and inactive plwh in which they found a lack of social support to be a barrier in engaging in pa 47 another qualitative study conducted in canada reported social influence such as encouragement from friends and health care providers as a facilitator to pa 58 a narrative review and a qualitative study reported that having an exercise partner or encouragement from staff members at the community facilities such as churches or community centres increased motivation and adherence to pa 2122 similarly another qualitative study reported that encouragement received from families and community members helped participants adhere to exercise and in many cases encouraged their children partners and neighbors to start exercising 41 authors reported that support from family members was a facilitator for exercise for instance a crosssectional study measuring benefits and barriers to pa among plwh in the united states showed that not receiving encouragement from a spouse significant other or family member was a perceived barrier to engagement in pa 59 the social setting where plwh were engaging in pa was also important mabweazara et al found that communitygroup exercise settings helped plwh stay motivated within a costeffective environment that facilitated socialbond formation 22 this was especially useful among plwh since stigma often led to lower levels of social support other studies found social support to be an important facilitator to engagement in pa including neff et al who reported social support was an important factor for motivating and continuing exercise 55 ley et al reported the need for social support or peer support but essentially trustful and confidential support from a good friend 51 and roos et al reported an important facilitator was the support and motivation received from friends and family through participating in sessions and walking with participants 60 in summary social support including encouragement from friends family members staff at the gym and peers in group exercise all appeared to be important facilitators to engaging in pa among plwh income and social status fourteen of the 41 articles examined relationships between income and social status on pa among plwh 2122363941475155585962677072 all 14 articles reported that financial constraints or costs were a barrier to participation in pa among plwh within different contexts and geographic locations for example a qualitative study among older exerciser and nonexerciser groups reported both groups identified costs as a barrier to exercise 36 similarly two qualitative studies among older adults living with hiv found cost was a barrier to pa 5558 a mixed method study found expense as a barrier to exercise in both hiv positive and negative groups 67 two of the studies focused on women from disadvantaged urban settings in south africa 51 and from the southern united states 59 and reported similar results examples of financial barriers were costs of a gym membership 39 and transportation to pa facilities 51 financial insecurity also led to food scarcity which was a barrier to exercise among plwh in kwazulunatal south africa 41 a systematic review incorporated one study in their review that highlighted the association between higher income and higher pa 70 education and literacy thirteen of the 41 articles reported on education and literacy and pa or exercise among plwh with varying results 35384246485254 61 62 63 687072 for example authors of a cohort study reported pa levels did not correlate with years of education 35 mabweazara et al reported education was not a significant predictor of overall pa among plwh 22 and dang et al found that high school education did not differ regarding pa compared to plwh with lower levels of education 42 another study reported no significant difference in pa stages of change related to education level 63 hsieh et al found higher levels of pa were significantly associated with lower education among chinese individuals living with hiv 48 alternatively some studies found the association between lower levels of education and lower pa level among plwh for instance a study reported participants who never attended school were less likely to engage in physical exercise compared to those who had secondary or higher education levels 022 95 ci 008 055 p 0001 54 similarly another study found low education was associated with physical inactivity 62 a narrative review conducted in south africa highlighted physical inactivity and obesity were strongly related to lower education level 72 nevertheless a few studies found an association between higher education and higher levels of pa mabweazara et al showed that educational attainment significantly predicted total moderatetovigorous pa among plwh of low ses in cape town south africa 68 another study reported participants with higher education reported more freetime pa than those with lower education among plwh from the swiss hiv cohort study 61 a mixed methods study examining patients preferences for hiv treatment in colombia found higher educated patients identified pa as the most important hiv treatment attribute whereas low educated patients valued accessibility to clinic over pa 46 employment and working conditions nine of the 41 articles reported on the relationship between employment and working conditions and pa among plwh 384248526063 68 69 70 results from these individual studies suggest that employment was associated with engagement in pa among plwh with higher levels of pa and exercise among those in nonsedentary jobs a crosssectional study showed that higher levels of pa was significantly associated with a higher likelihood of manual labor versus nonmanual labor occupation 48 another crosssectional study reported unemployed plwh had a 281 higher odds of not adhering with pa recommendations compared with employed plwh 38 a crosssectional study found that bluecollar workers or farmers were more likely to have a higher international physical activity questionnaire score and were classified as physically active compared with whitecollar workers 42 similarly a rct found that sedentary jobs prevented plwh from achieving adequate step counts as well as following their pa programme outside of work due to fatigue and busy schedule among plwh in south africa 60 a crosssectional study reported employment was a significant predictor of overall pa 22 conversely a crosssectional study found no difference in employment status between the different stages of change in regard to pa 63 one metaanalysis revealed dropout rates in pa interventions in plwh were not moderated by employment status 69 physical environments thirteen of the 41 articles reported on the relationship between physical environment and pa or exercise among plwh 213647515556 58 59 60 67 70 71 72 physical environment often was described as either a barrier or facilitator to participating in pa a qualitative analysis described how physical environmental factors such as gym culture feeling unsafe in their neighborhood or lack of affordable housing were barriers to pa among plwh 36 nguyen et al also found in their qualitative inquiry that perceived safety or culture in the gym environment was a barrier specifically pertaining to exercising in nonpositive spaces due to fear of stigma 56 another qualitative study reported hivpositive exercise programs were a facilitator to pa by creating a safe and inclusive environment 21 a mixed methods intervention study reported a lack of safety and security in disadvantaged areas as a barrier to pa among south african women living with hiv 51 another mixed methods study found safety concerns was a common barrier to pa among plwh in uganda 67 in their narrative review ley and barrio reported that limited space and desolate living conditions failed to offer suitable environments to engage in pa in south africa 72 two qualitative and one mixed method studies found that climate constraints were a barrier to engaging in pa 475860 lastly a qualitative study among older plwh reported that convenience of location to an exercise facility was a motivating factor to initiate exercise 55 while the sdoh physical environments can refer to many different concepts common themes were gym culture safety and climate healthy behaviors nine of the 41 articles reported on healthyunhealthy behaviors in relation to pa among plwh that largely concluded smoking and substance use did not have an influence on engagement in pa 36384854 61 62 63 6970 we did not include physical activity as a healthy behavior since it was our outcome of interest hsieh et al found that smoking and alcohol use were not significantly related with pa 48 similar findings were reported in a crosssectional study where no association was found between smoking and alcohol use and adherence to pa 38 one qualitative study reported drug use as a barrier to pa and exercise 36 only one systematic review examined drop out rates among plwh engaged in pa or exercise and reported smoking status did not moderate dropouts rate 69 culture five of the 41 articles reported on culture with pa or exercise among plwh 4143517172 a narrative review and one mixed methods intervention study examined the cultural barriers to exercise among women in the black african community 5172 in the disadvantaged community for example women generally are not seen running in the street due to socialcultural norms and attitudes 51 a mixed method study also discussed cultural perceptions of exercise as a barrier for plwh engaging in pa many participants were apprehensive about exercise in terms of their cultural practices and were not sure if this was something they would really do 43 finally a qualitative study examined stigma as a cultural factor as a barrier to engaging in pa 41 339 raceracism six of the 41 articles reported on race and racism among plwh with mixed results 355762697072 two studies showed no race difference in pa for instance a longitudinal study in the united states found pa did not differ by white vs nonwhite plwh t 012 p 091 35 in a systematic review authors found that the dropout rate from pa programs was not moderated by race or ethnicity among plwh 69 authors of a narrative review found black women living with hiv experienced barriers to engaging in pa due to cultural perceptions addressing the intersection between gender race and culture 72 an observational intervention study reported the proportion of black african plwh among a group nonadherent with pa and the white british in a group adherent to pa were significantly higher authors suggested further investigation on the relationship between race and pa among plwh 57 in a systematic review authors could not ascertain a relationship between race and pa among plwh among the included studies as one study showed higher pa among the nonwhite plwh while another showed the opposite and four studies showed no association between race and engagement in pa or exercise 70 discussion to our knowledge this is the first scoping review that examined the nature and extent of evidence on the relationship between sdoh and engagement in pa or exercise among adults living with hiv our findings indicate that gender was the most common sdoh among included articles followed by social support and coping skills and income and social status most included articles explored the relationship between sdoh and pa or exercise in plwh as a primary aim whereas the rest of the articles reported sdoh as a secondary aim among the 23 quantitative studies the majority used a crosssectional design that prevented establishing a causal relationship between the sdoh of interest and engagement in pa or exercise eight qualitative studies highlighted socioenvironmental factors as barriers and facilitators of pa or exercise with financial cost social support cultural context and physical environment as the most common sdoh influencing engagement in pa or exercise among plwh despite the explicit focus of articles examining relationships between different sdoh and pa or exercise among plwh none of the articles used a sdoh framework to inform their analytical approach in addition a large number of studies examined only a single sdoh 34373940 43 44 45 49505356 64 65 66 while only one systematic review evaluated eight sdohs identified in the phac framework 70 identifying more than one sdoh is important to evaluate the intersection between different determinants although some studies evaluated more than one sdoh in relation to pa or exercise separate results were reported for each determinant in two studies women from low ses 37 and black african women from disadvantaged communities were found to engage in low pa or exercise 51 none of the other studies appeared to report the impact of intersectionality on pa or exercise this scoping review indicates an evidence gap in the literature as childhood experiences biology and genetic endowment and access to health services were not reported in the included articles highlighting the need for future research to address these determinants and and the impact of combinations of sdoh among plwh engaging in pa or exercise results from individual studies in this scoping review suggest that women living with hiv engage in less pa compared to men living with hiv only one study reported higher pa among women 42 whereas other studies reported nonsignificant findings however women were underrepresented in most of the included studies gender remains an important sdoh to consider in the context of pa and exercise among plwh while gender was the most common sdoh addressed in the review genders other than men and women were underrepresented only five studies included other genders 4649566566 among which one study reported combined female and transgender data 56 moreover some studies utilized sex and gender interchangeably transgender groups are at higher risk of hiv specifically transgender women have 49 times the odds of having hiv compared to the general population 73 thus future studies should consider other genders in addition to men and women on engagement in pa or exercise among plwh our review suggests no association between unhealthy behaviours such as smoking and alcohol use with engagement in pa smoking and alcohol consumption are not considered as healthy behaviors because of their adverse impacts on physical and mental health 7475 interestingly a crosssectional study from brazil reported a higher level of pa among young middle aged and older adults who were weekly alcohol consumers 76 we recommend evaluating the relationship between healthy or unhealthy behaviours and pa or exercise in larger populationbased studies involving plwh our findings suggest that stigma associated with culture and raceracism were underrepresented in the literature with only 12 and 15 of included studies addressing these sdoh respectively while one systematic review was inconclusive regarding the relationship between race and pa 70 authors of one narrative review suggested engagement in pa was lower among black women due to perceived barriers 72 some literature was suggestive of an association between white race with higher pa in general population for example one study conducted a secondary data analysis from the national health and nutrition examination survey of 9472 adolescent and young adult respondents from 2007 through 2016 reported white race and higher income were associated with greater pa in adjusted models 77 the centre for disease control and prevention conducted a behavioral risk factor surveillance system among 52 united states jurisdictions from 2017 to 2020 and showed lower prevalence of physical inactivity outside of work among nonhispanic white compared to nonhispanic black participants 78 based on the 20032009 american time use surveys data saffer et al showed nonwork pa was significantly lower among blacks relative to nonhispanic whites 79 conversely total work related pa was significantly higher among black peoples compared to white and asian peoples given the context that black individuals were more likely to work in bluecollar and physically demanding occupations 80 although these findings involve the general population the association between race and pa engagement among plwh needs further evaluation we recommend examining the intersection between race gender employment education and culture among plwh to better understand engagement in pa or exercise this review identified gaps in the literature related to sdoh and engagement in pa or exercise among hiv definitions of pa and exercise varied significantly across the studies none of the included studies adopted a sdoh framework as the theoretical basis for their work additionally authors used a variety of selfreported questionnaires and objective measures of pa and exercise considering the diversity in pa definition and assessments and benefits and limitations of objective versus selfreport of pa researchers should consider the inclusion of an operational definition of pa or exercise in future work and provide a rationale for the selection of the pa or exercise assessment tools similarly authors examining sdoh should better define the determinant of interest and the research context clearly defined pa exercise and sdoh variables using a conceptual framework to guide the analytical work and standardized and validated outcome measures should improve the interpretation of evidence in this field and foster standardized approaches in future research furthermore the majority of studies were crosssectional in nature making it difficult to identify the causal relationship between sdoh and pa or exericse future longitudinal or cohort studies among plwh may help to further understand the strength and direction of the relationships and whether pa or exercise is a moderator or mediator of health outcomes among plwh another major gap in the evidence is the absence of research on the impacts of the intersection between multiple sdoh on pa and exercise finally many studies included small sample sizes with unclear transferability to the broader hiv population highlighting the need for a richer understanding of the collective influence that a combination of sdohs have on engaging in pa or exercise among plwh other research has explored the relationship between sdoh and physical activity or exercise among other chronic illness populations this body of work has also documented that the ability for individuals to engage in exercise is affected by cost health status and disability 80 social determinants research in other chronic conditions found similar barriers and facilitators of engagement in pa for example people living with diabetes with a low socioeconomic status and lower education level found it difficult to engage in pa regularly 81 in a study conducted with adults living with multiple chronic conditions an unsafe environment which attributes to low socioeconomic status and housing were correlated with lower engagement in pa 82 one qualitative study among people with type 1 diabetes who progressed to endstage renal disease identified lower socioeconomic status lower education level and female gender as barriers to pa 83 social support and inclusion were also determinants and found to facilitate and encourage engagement in adults living with chronic conditions 84 strengths of this scoping review includes our rigorous adherence to wellestablished scoping review methodology 242527 our broad selection criteria involving a range of study designs and methodologies and our team based approach involving independent review and multiple piloting of the inclusion and data extraction process we did not assess quality of the included studies as this is not a requirement of scoping reviews but rather to provide an overview of the evidence 25 potential limitations of our review is that we may have missed relevant articles despite our extensive search strategy of multiple databases we contacted the corresponding authors of titles and abstracts without fulltext articles and waited up to 4 weeks before excluding them we only included english language articles because of the cost and time associated in translating foreign materials despite these limitations this review provides important insight into the nature of extent of evidence on the role of sdoh on engagement in pa or exercise among plwh conclusions this scoping review characterized the evidence examining the role of sdoh on pa or exercise among plwh gender was the most commonly reported sdoh in the literature with the majority of studies addressing only one sdoh results from individual studies suggest that social support is a facilitator and financial constraints and costs are a barrier to engagement in pa or exercise among plwh results of this review may help to inform clinicians researchers and policy makers to better understand the role of sdoh as potential barriers or facilitators while promoting or evaluating pa or exercise with plwh future research should consider the intersection between different determinants to better understand the combined impact of different determinants on engagement in pa or exercise data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation cobbing and chetty 2019 41 x x x

physical activity pa and exercise are an effective rehabilitation strategy to improve health outcomes among people living with hiv plwh however engagement in exercise among plwh can vary our aim was to characterize the literature on the role of social determinants of health sdoh on engagement in pa or exercise among adults living with hiv we conducted a scoping review using the arksey and omalley framework we searched databases between 1996 and 2021 we included articles that examined pa or exercise among adults with hiv and addressed at least one sdoh from the public health agency of canada framework we extracted data from included articles onto a data extraction charting form and collated results using content analytical techniques of the 11060 citations we included 41 articles with 35 studies involving primary data collection 23 66 quantitative 8 23 qualitative and four 11 mixed methods of the 14835 participants 6398 43 were women gender n 24 articles social support n 15 and income and social status n 14 were the most commonly reported sdoh in the literature with the majority of studies addressing only one sdoh future research should consider the intersection between multiple sdoh to better understand their combined impact on engagement in pa or exercise among plwh

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introduction many international professionals and scholars have recognized the significance of endoflife care and grief as a public health issue 1 2 3 4 5 as a result a global movement compassionate citycommunity has been formed this paradigm shift is occurring in medical systems it necessitates community partnerships and community energy to build mutual support providing a supportive environment for palliative care and grief counseling 6 inspired by the healthy cities or healthy communities program of the world health organization cc is a concept pioneered by professor allan kellehear of the university of bradford in the united kingdom this public health notion first emerged in the 1980s and policies and practices in the field of health education can be dated back even further 78 according to this health is more than just diseasefree the new concept urged the general population to recognize that health is no longer the sole responsibility of doctors and hospitals but everyone hospitals can assist patients suffering from accidents disabilities or acute or chronic diseases however prevention and early intervention are the most effective treatments the spirit of this new wave of public health is prevention harm reduction and early intervention 78 this health city movement has urged the government workplaces schools and other social organizations to offer relevant policies mass media and legislation have discouraged people from using harmful substances or staying in harmful conditions thereby adopting a healthy lifestyle kellehear built the principles of health promotion healthcare 2022 10 177 2 of 10 particularly the ottawa charter advocating that health promotion and wellbeing should be complimentary he integrated these two ideas to develop a health promoting palliative care paradigm kellehear also criticized the narrowing of the traditional palliative care approach of medical treatment and the care of dying patients he thought that palliative care should include the following components improving selfcare and support for patients with chronic or terminal illnesses providing education and information regarding health death and endoflife care providing personal and community social support encouraging rethinking palliative care and fostering the collaboration between health promotion and palliative care 9 currently palliative care is defined by the who as a crucial part of integrated and peoplecentred health services it is a global ethical responsibility to relieve severe healthrelated suffering be it physical psychological social or spiritual 10 since then hospices and palliative care providers have encouraged medical organizations to accept death as a natural part of the human experience these ideas had been advocated gradually from the late 1990s to the early 2000s they have now been expanded to public health and medicine 6 professor kellehear took the lead to bring the concept of health promotion into hospice and palliative care because anxiety despair social isolation social prejudice social exclusion family disintegration unemployment financial restrictions spiritual distress or crisis and even suicide may occur in terminal patients as well as the surrounding relatives and friends 11 these are essential aspects that influence quality of life many social psychological and spiritual issues are too complex for medical institutions to address effectively and become even more difficult in the patients final days of life a new wave of cc movements is emerging 12 13 14 15 in 1993 kozhikode india was the first funded cc in asia the project included marginalized groups such as the elderly and the mentally ill who were compassionately cared for through community participation in 2015 the local administration decided to expand its efforts by establishing a platform called compassionate kozhikode currently psychiatric institutions receiving frequent community support communitybased rehabilitation plans for chronic mental disorders and various disadvantaged groups have also been included in compassionate kozhikode with students being permitted to participate 16 cc in different countries or communities adopts different strategies and develops different programs the cc in vic spain embraces positive cultural social attitudes and activities toward the end of life provides a comprehensive and integrated care system and avoids and minimizes suffering 13 due to the medical assistance in dying legislation and the growing elderly population the canadian government began to provide leadership education and promotion programs to help communities across the country understand and establish their cc with reverence to the local culture to support community members going through the experience 14 canada has a nationallevel promotion organization eg pallium canada a nonprofit organization established in 2001 to promote crossdisciplinary palliative care education 15 through education courses the provision of tools and resources the improvement of the fairness of obtaining palliative care and the empowerment of frontline workers and nonprofessional caregivers the organization promotes the health of the entire population and supports patients and their families by fostering community energy resilience and community transformation 17 the medical orders for lifesustaining treatment in new york a patientcentered shared medical decisionmaking program successfully collaborated medical treatment with the community 12 in osaka japan a social welfare organization has constructed a community daycare center to help patients manage their daily lives they expect collaboration from the community and social service departments to help people comprehend the concept of cc develop problemsolving skills enhance the experience of dying the loss of relatives and friends and meet their welfare needs 11 according to the above literature review we have seen cc built by different groups and organizations and different levels of government administration in the context of different cultural and historical backgrounds however there is still a lack of discussion of value dissemination what strategies are adopted and how people organizations and the government should work together this project report discusses the cc implementation experiences and preliminary outcomes in the capital of taiwan taipei city we will describe the ccs core values and strategies such as humanistic care social network holistic care and life wisdom through specific health care interventions including home health care services workshops conferences and the life issue cafe in cooperation with a hospital and other social services a cc has been implemented in the shilin old street neighborhood and later multiplied in other communities the following sections explain how we developed the shilin old street community by applying international theory and experience and blending with the local culture and how we constructed a publicprivatepartnership framework by connecting government agencies communities social welfare institutions businesses charitable and religious organizations and other nongovernmental organizations implementation methods the cc in taipei is a significant effort initiated by the city government and a community hospital it was developed from yearlong efforts of community health promotion 18 and health literacy for shilin old street professor allan kellehear inspired the idea of building shilin old street into a compassionate community when he was invited as a keynote speaker at the compassionate city workshop entitled agefriendly dementia friendly palliative friendlysupporting a comfortable and independent life for the elderly in november 2017 hosted by the health promotion administration ministry of health and welfare taiwan after a discussion with professor allan kellehear the administrators of the taipei city hospital thought that the shilin old street community was a perfect spot to promote the cc program death literacy which cc promotes 19 can combine with health literacy and become a complete life literacy program that should be provided in community care from life to death the mhw began encouraging community health promotion in 1999 facilitating collaboration between the community public and private sectors to tackle health problems and improve the quality of life for people in the community assetbased community development was then added in 2017 for longterm development utilizing a resource inventory emphasizing community participation and empowering to solve problems and implement strategies to jointly promote the health of community residents the shilin old street neighborhood refers to the region surrounding shilin shennong temple which is currently known as the jiujia village of shilin district and was the oldest historically developed place located in the centre of the community shilin shennong temple is a listed historical heritage and folk belief center nearby lies the guo yuanyi cake museum a centuryold bakery where visitors can learn about history and traditions shilin old street community represents a mixture of modern and nostalgic culture because of a nearby mass rapid transit station the majority of the population has lived there for decades with only a handful relocating from elsewhere according to population statistics the current population is 6201 with those aged over 65 accounting for 3329 of the population which is higher than the taipei city average of 1922 and the national average of 1405 20 a health intervention known as the shennong lohas station was established through a collaboration between the taipei city hospital and the village head this station is characterized by the local culture and folk religionwhere people gather worship regularlyand is integrated with healthcare services twice a month the lohas station provides meals healthcare counseling and health talks on the first and fifteenth days of the lunar calendar the nearby taipei city hospital yangming branch also offers home medical care and mealsonwheels services the station also works with local ngos for the disabled and the disadvantaged all activities included the components of community heritage and culture eg shennong in folk belief as to the ancestor of chinese medicine and health seminars with chinese medicine topic by pursuing the components of the international compassionate city charter we solidified the core value of the shilin old street cc and formed strategies that suit the reality we aimed to build a culturally sensitive sustainable and holistic cc program by integrating municipal hospital social and other services and collaborating with community leaders ngos university students and volunteers innovative programs were presented to enable engagement public education and leadership furthermore we organized exhibitions of life aesthetics to raise community awareness of endoflife issues and explained the evolution of endoflife care the four strategies humanistic care social network holistic care life wisdom are explained as follows medical care and mealsonwheels services the station also works with local ngos for the disabled and the disadvantaged all activities included the components of community heritage and culture eg shennong in folk belief as to the ancestor of chinese medicine and health seminars with chinese medicine topic by pursuing the components of the international compassionate city charter we solidified the core value of the shilin old street cc and formed strategies that suit the reality we aimed to build a culturally sensitive sustainable and holistic cc program by integrating municipal hospital social and other services and collaborating with community leaders ngos university students and volunteers innovative programs were presented to enable engagement public education and leadership furthermore we organized exhibitions of life aesthetics to raise community awareness of endoflife issues and explained the evolution of endoflife care the four strategies humanistic care social network holistic care life wisdom are explained as follows humanistic care we hold activities such as the festival of life to encourage people to share stories of their life and use events such as life aesthetics to preserve cultural legacy we also host the life issue café to talk about the issue of life ie health literacy and death literacy in doing so we believe mutual trust empathy social connection and solidarity within the community can be rebuilt social network we use round table meetings to establish consensus among members of the community and organize a neighborhood watch to improve safety and offer support such as meal together long term care resources and assistant living for the disadvantaged disabled and the living alone thus a friendly environment can be arranged this can be conducted by collaborating with nearby groups and organizations humanistic care we hold activities such as the festival of life to encourage people to share stories of their life and use events such as life aesthetics to preserve cultural legacy we also host the life issue café to talk about the issue of life ie health literacy and death literacy in doing so we believe mutual trust empathy social connection and solidarity within the community can be rebuilt social network we use round table meetings to establish consensus among members of the community and organize a neighborhood watch to improve safety and offer support such as meal together long term care resources and assistant living for the disadvantaged disabled and the living alone thus a friendly environment can be arranged this can be conducted by collaborating with nearby groups and organizations holistic care our program utilizes home medical care home pharmacists home rehabilitation home care and home palliative care services of the taipei city hospital to offer health promotion and education screening prevention to delay disabilities of the elderly and increase health and death awareness as such people in every stage of life can receive proper support and care the wisdom of life and death the wisdom of pursuing a good life and good death is rooted in the folk the purpose of palliative care is to promote a good death we have created the bucket list fulfil project to help the dying and their family to have an opportunity to love say goodbye thank and apologize to each other we offer advance care planning section to help people finish their advance directive and the home care team in taipei city hospital also offers grief counseling and spiritual care we train community volunteers to care for the disadvantaged population petfriendly services are offered since many people take pets as family members and the loss of a pet should be considered grief the shilin old street cc formed a promotion committee and invited professionals scholars and social talents to advise the promotion initiatives various activities such as the life issue café lectures life story microfilm competition book clubs aesthetic activities and exhibitions drawing competitions essay competitions pet adoption reunion and memorial activities environmentally friendly campaigns and roundtable meetings were held to create a trustworthy atmosphere and offer a sense of identity belonging and participation this experience and preliminary outcome compared with previous cc models around the world we would like to highlight some significance from our practical experiences including communication with the endusers collaboration with stakeholders and education for service providers first communication with endusers is critical because their understanding of the program and their willingness to be involved is crucial however it was considered impolite in traditional taiwanese society to discuss death directly especially with the elderly in order to promote a culture of compassion with one another especially regarding the issue of death and dying people need to see that death is a natural part of life and their death literacy needs to be improved to establish a supportive network in the community we first utilized existing social networks and held activities such as seminars conferences and the life issue café to facilitate more public engagement one of the creative activities we often held was the intergenerational life issue café we brought the young and the old together to learn through mutual empathy and exchanges of life experience these shared learning processes exposed the elderly to social energy and young people which transformed the notions and beliefs of the older generations and injected the new concepts and ideas from the young while introducing selfidentity life objectives and interpersonal connections to the elderly to improve community flexibility the life issue café aided the young to participate innovative thinking and the transmission of experience from the elderly by participating in community activities the elderly can reduce cognitive function deterioration through communication and mutual support the life issue café is different from the death café in previous studies 21 because it does not directly touch the issue of death but instead rationalizes the importance of compassion firstly through discussion and engagement it is inspired by the milford care centre s compassionate communities project that uses café conversation to engage their communities in discussion about death dying loss and care 22 the method explores collaborative creativity and thought through flexible small group talks during the debate one can interact to link diverse viewpoints listen to reach consensus think on the problem and even devise a new course of action several life issue cafés have been held allowing the aged to discuss the theme of life death and dying generations and injected the new concepts and ideas from the young while introducing selfidentity life objectives and interpersonal connections to the elderly to improve community flexibility the life issue café aided the young to participate innovative thinking and the transmission of experience from the elderly by participating in community activities the elderly can reduce cognitive function deterioration through communication and mutual support the life issue café is different from the death café in previous studies 21 because it does not directly touch the issue of death but instead rationalizes the importance of compassion firstly through discussion and engagement it is inspired by the milford care centre s compassionate communities project that uses café conversation to engage their communities in discussion about death dying loss and care 22 the method explores collaborative creativity and thought through flexible small group talks during the debate one can interact to link diverse viewpoints listen to reach consensus think on the problem and even devise a new course of action several life issue cafés have been held allowing the aged to discuss the theme of life death and dying university students were invited to join with the elderly to explore these issues the duration of the meeting is approximately 15 h with each round of dialogue lasting for 20 min there are three rounds in total after which collective knowledge is visually generated and the content is shared the life issue cafe is a simple adaptable and efficient way to give people a sense of identification belonging and participation in the community in which they reside according to our preliminary study four events were held in 2018 with 27 senior individuals and 60 students attending the results of two questionnaire surveys showed the attitudes of the senior individuals versus young students toward death 842 vs 909 believe it is vital to address life and death matters with people 579 vs 455 expressed however that it is difficult to do so 789 vs 909 believed they have the ability to face death calmly 23 second the collaboration among stakeholders within communities is also important to us in order to encourage a sense of solidarity and establish a close friendship with all social groups and organizations we held regular visits to the community care center to teach young students and help them realize the importance of healthy living and endoflife care the shilin old street cc worked with university students who visited the elderly in good health subhealth disability and endoflife and followedup regularly through conversations and activities with the seniors students engaging in this project learn the fundamental meaning of life and the elders can adopt healthy views university students were invited to join with the elderly to explore these issues the duration of the meeting is approximately 15 h with each round of dialogue lasting for 20 min there are three rounds in total after which collective knowledge is visually generated and the content is shared the life issue cafe is a simple adaptable and efficient way to give people a sense of identification belonging and participation in the community in which they reside according to our preliminary study four events were held in 2018 with 27 senior individuals and 60 students attending the results of two questionnaire surveys showed the attitudes of the senior individuals versus young students toward death 842 vs 909 believe it is vital to address life and death matters with people 579 vs 455 expressed however that it is difficult to do so 789 vs 909 believed they have the ability to face death calmly 23 second the collaboration among stakeholders within communities is also important to us in order to encourage a sense of solidarity and establish a close friendship with all social groups and organizations we held regular visits to the community care center to teach young students and help them realize the importance of healthy living and endoflife care the shilin old street cc worked with university students who visited the elderly in good health subhealth disability and endoflife and followedup regularly through conversations and activities with the seniors students engaging in this project learn the fundamental meaning of life and the elders can adopt healthy views community care visits allow college students to access the community successfully combine school education theory with community practice and improve social connections and the involvement of the elderly third we think education for service providers is essential for promoting this new idea of community movement succeeding the execution of the tactics mentioned above we held lots of education and training programs for the hospital staff and community volunteers in order to establish understanding and consensus of the program vision and values in doing so community members can actively participate in social lives share experiences and information and help one another following in the footsteps of the shilin old street cc taipei city has recently developed cc in other administrative districts the model has been replicated and there are now 20 compassionate communities spread across the 12 districts of taipei city the scope from community participation in endoflife care to the integration of medical treatment and community resources to improve health care quality communities with varying features were created and each cc had its unique traits eg the huxing village cc in neihu district with elderly beliefs the hulu village cc with a petfriendly environment the changchun village cc with friendship and other districts with their own regional characteristics discussion glocalization of cc glocalization refers to a fusion of globalization and localization signifying an increase in the relevance of continental and global levels as well as an increase in the importance of local and regional levels reflecting both local and global considerations 24 according to robertson the genuine process of globalization includes the localization process within certain conditions and contexts robertson advocated a dual and mutual process that transforms localized models into global trends and goals 25 when global universality is applied to other locations it assimilates local traits and conditions and becomes locally exclusive we believe the cc development is a glocalization process theory practice guidelines and standards are distributed over an international network while each cc was formed to meet local culture and community conditions collaboration partnership and integration the majority of cc organizations develop alliances by combining various types of public and private organizations including those of education medical care social services culture religion volunteer business and nonprofit organizations all fields of health and social care professions such as palliative care homes communities and medical care longterm care physicians and social workers need to participate all partners must work together through open communication and a shared vision whichever launches the cc in taipei the cc evolved from a health promotion background and merged with palliative care we believe in holistic care that integrates the personal needs for physical psychological and social wellbeing and the care needs ranging from healthy people to palliative care patients the convergence of wellbeing and palliative care is critical for the entire community communication and public education a good communication plan is required to make people aware of the importance of open discourse concerning palliative care and death literacy it is critical to boost communication and educate the people on the relevance of the government policies for endoflife care communication is essential for a successful collaboration to achieve the same aims and speed up the promotion of cc as people have taboos about dying death and grieving and they are hesitant and fearful of addressing death public education is critical to changing society forming a culture of compassion and sharing care obligations towards the end of life there are also difficulties such as a reluctance to ask for or accept help from others and provide assistance education should extend beyond campus and communities to improve social connectivity and death literacy professionals such as physicians nurses and caregivers may also need to incorporate death education into their curricula as dying death and mourning are not currently taught 426 people of all ages and backgrounds must confront loss and experience death and bereavement necessitating the provision of death and grief education local culture and religions care dying death and grieving occur in all aspects of our daily lives and human interactions and they have always been impacted by local culture and religious beliefs 27 cultural or religious beliefs may influence ones reactions and subsequent behaviors 28 it may help one to understand the difficulty of caring for the loved one who is seriously ill recognize the cycle of life and affirm the spirit of cc partnerships with religious groups are viable to create a compassionate and caring community 29 similar to other temples and christian churches the shennong temple helps promote palliative care and endoflife education in the community encourages its followers to cultivate and exercise compassion and grasps the vocabulary and practices of palliative care covid19 pandemics and cc the outbreak of the covid19 pandemic has brought increased death and dying into communities requiring new demands that significantly alter the social engagement patterns everywhere social care and volunteering halted because they are deemed too dangerous despite this people still want to connect take action and support those in need the cc in taipei is wellestablished and has not stepped back during the covid19 pandemic but continues to support its community members and presents strong solidarity and support to the health professionals according to the advocate posted on the public health palliative care international website compassionate streets and neighborhoods can respond to the covid19 pandemic by mobilizing community helpers providing practical assistance and emotional support and building local communications through information technology providing both physical and mental support is a demand of the heart and our compassionate response in the time of adversity brought by the covid19 pandemic 30 cc can offer established support and social connections to those dealing with death dying loss and caring conclusions cc has actively created a sense of solidarity tranquility and enjoyment in the community by capitalizing on the need for aged care and ageing in place this strategy acquires worldwide and local support and collaboration with the medical teams universities and ngos we believe that the government and people working together can foster a friendly caring community for the elderly and form a caring community model from birth to death this project report presents a paradigm of collaboration that combines health promotion palliative care and community assistance many education and training courses and communitybuilding activities were conducted using a culturally sensitive approach and appropriate health and endoflife care were provided the collaboration between hospital and community groups has resulted in positive and meaningful experiences for caregivers and patients community involvement lessens the workload of the hospital palliative care team and offers further service quality improvement the tentacles of palliative care and service can be extended to more persons in the community who have terminal diseases or require palliative care through activities an ideal cc is a collaborative effort of caregivers family members friends neighbors volunteers and the palliative care staff the general public has diverse perspectives on death dying and grieving due to the diversity of cultural background religious beliefs and life experience these are commonplace experiences for most people but may be difficult for medical experts to comprehend the demands and difficulties necessitate community participation to prioritize the wellbeing of all community members as a result strengthening the collaboration is a viable option for cc our practical experience has shown that empowering the community may effectively improve their capacity to deal with death dying and bereavement issues by forming alliances and empowering the community we can help bereaved families receive care from their community and eventually return to regular life spiritual care in our cc has become a regular topic of conversation among community members the shilin old street ccs experience intends to motivate more government agencies hospitals and communities to participate and improve the overall quality of endoflife care this culturally sensitive sustainable and holistic cc model bridges the bereavement support gap in palliative care by combining the municipal hospital social and other services and partnering with community leaders ngos university students and volunteers our intergenerational learning activity between the young and old is novel it improves the sense of belonging of the elderly and creates a generationfriendly community participation of young students also allows them to apply what they have learned and return the favor to society thus developing intergenerational reciprocity

a worldwide movement to empower communities to support their members to care for each other at the end of life eol has emerged since kellehear published the compassionate city charter this current report discusses the implementation experiences and preliminary outcomes of compassionate communities cc in taipei city using the guidance of the charter and international experiences we have developed and multiplied a culturally sensitive sustainable and holistic cc program that composes municipal hospital social and other services partnering with community leaders nongovernmental organizations university students and volunteers innovative campaigns such as workshops conferences and the life issue café have been delivered to facilitate engagement public education and leadership with reverence to folk beliefs and the use of existing social networks we have identified a model with strong collaborative leadership high participation rates and ongoing commitment the gaps between askingaccepting and providing help were bridged when social connectedness was strengthened we also integrated homebased medical care homebased palliative care and advance care planning to help the vulnerable who live alone with poor status or with limited resource access and continue to support the community throughout the covid19 pandemic

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introduction conflict is a challenge common to many sectors with healthcare sector inclusive 1 in this context conflict refers to clash of interest opinion or principles among healthcare workers whilst rivalry is associated with engaging in competitive relationship and this can also result to conflict available evidence suggests that conflict is significantly higher in the health sector due multifaceted and regular interaction among healthcare professionals 2 conflict is a phenomenon that can arise at all levels within the healthcare space and has been identified as a global problem 3 4 5 6 7 the primary obligation of healthcare workers is the wellbeing of patients 8 however factors such as organisation hierarchy specialisation and multiplicity of skills have created rivalry among this group of service providers 9 another notable factor which has contributed to rivalry is power struggle among various groups of healthcare professionals over the control and leadership of work process 10 also various health professional associations act as interest groups to influence government policy in favour of open access correspondence pharmacists council of nigeria plot 79 industrial layout idu pmb 415 garki abuja federal capital territory nigeria their members ignoring the implication to other professional groups and the health sector in general provision of healthcare services involves multidisciplinary measure which requires doctors pharmacists nurses medical laboratory scientists and other healthcare professionals with different area of specialisation to work as a team 11 multidisciplinary collaboration among healthcare workers can optimise quality of care and result in improved outcome for patients 12 interprofessional rivalry is detrimental to both patients and the healthcare system available evidence suggests that conflict or rivalry in the health sector disrupts intra and inter sectorial collaboration 13 and can also result to aggravated stress including emotional exhaustion for healthcare workers interprofessional rivalry has also been implicated in reducing the commitment of healthcare workers to healthcare services 14 as well as encouraging selfish behaviour 15 which consequently results in mistreatment or nontreatment of patients the nigerian health sector has witnessed unhealthy rivalry among healthcare professionals for decades this has led to several industrial action such as strike 10 and thereby hampering sustainable development in the sector the rivalry in the sector is mostly between medical doctors and other healthcare professionals 16 whilst other healthcare professionals have blamed doctors of being at the helm of affairs of the entire sector the doctors on their part had also alleged other healthcare professionals of uniting together to fortify a joint force against them 17 the healthcare delivery system in nigeria is a blend of private and the three tiers of government with federal government responsible for the affairs of tertiary health facilities the state governments taking charge of secondary health facilities and the local governments in charge of the affairs of primary healthcare centres 18 available evidence reveals the existence of incessant rancour among healthcare professionals in the country with a number of such rancour degenerating into fullblown conflict and sometimes industrial dispute 10 despite the vulnerability of the nigerian health sector to conflict situations only few studies have been undertaken in this area it is against this backdrop that this study therefore aimed at understanding knowledge causes and experience of interprofessional conflict and rivalry among healthcare professionals in nigeria methods a crosssectional survey was undertaken in nigeria between april and june 2021 a data collection tool was designed in english language following an extensive literature review 3461617 an iterative process involving a panel of faculty members in health sciences was used to develop the items the panel consisted of 4 members from two institutions members of the panel were engaged in teaching and research activities in this area a draft version of all the items in the instrument was reviewed by the panel each person reviewed the items independently and suggested changes additions and deletions the revision process continued until a consensus was reached the questionnaire items were structured to gain insights on knowledge causes and experience of interprofessional conflict and rivalry among healthcare professionals in nigeria face and content validation of the instrument were undertaken using an independent expert panel comprising 6 faculty members the questionnaire was assessed for appropriateness complexity attractiveness and relevance some of the statements were edited and reworded whilst content validity was evaluated by quantitative method content validity ratio and content validity index were tested for each item and only those that passed these tests were included in the final questionnaire the questionnaire was pretested by administering it to initial 30 participants comprising different healthcare profession selected randomly the feedback received did not warrant any major change data were collected using online and physical methods of questionnaire administration this was to ensure that a good number of healthcare professionals participated in the study the participants were selected using stratified sampling method two states were selected randomly from six geopolitical regions in nigeria snowball sampling strategy was employed during the online data collection process 1920 and this involved the use of whatsapp the link to the survey was sent to various groups made up of current practicing healthcare professionals participants were asked to send the questionnaire to their colleagues practicing in the same state with them hard copies of questionnaires were administered physically to doctors pharmacists medical laboratory scientists nurses and other healthcare workers in several healthcare facilities that were randomly selected from each state using convenience sampling method the physical administration commenced after the link to online data collection was closed prior to the paperbased questionnaire administration participants were requested to indicate if they had previously responded to online version of the questionnaire and only healthcare practitioners who did not participate during the online data collection process were given hard copies of questionnaires to complete inclusion criterial were healthcare professionals who are currently practicing in nigeria and with current annual license to practice and all participants who did not meet these criterial were excluded from the study the study was a national survey and data were collected from multiple health facilities in nigeria ethical approval was obtained from national health research ethics committee of nigeria as they are responsible for granting approval for studies involving multiple centres this approval was obtained before the commencement of data collection participation in the study was voluntary as informed consent was obtained prior to the administration of questionnaires confidentiality was maintained by not including the names of the study participants in the data collection tool following the importation of data collected into statistical package for social sciences software version 25 descriptive statistical analysis was carried out associations between variables were tested using chi square test a pvalue of 005 or less was considered the threshold for statistical significance results demography and response rate a total of 2000 copies of paperbased questionnaires were administered and 2207 valid responses were received comprising 503 online and 1703 paperbased respondents response rate for paper questionnaire was 852 male participants represented twothirds of the respondents respondents above 60 years of age were in minority whilst those between 41 and 50 represented the most populous proportion of the sample as indicated by 328 majority of the study participants had first degree as their qualification further details about sociodemographic characteristics are presented in table 1 below sources of conflict interprofessional conflict among healthcare team is known to hinder high quality healthcare delivery findings in fig 1 shows that the most common source of conflict is salary structure as indicated by 795 of the study participants and this is closely followed by leadership of agencies and rivalry whilst the least source of conflict is professional socialisation lack of team work allowances lack of respect disparate entry level and lack of collaborative training at undergraduate level also have significant role in promoting conflict in the healthcare sector as more than half of the study participants indicated each of them as sources of conflict in the sector knowledge of conflict and rivalry findings from this study revealed that more than half of the study participants disagreed that interprofessional conflict in nigerian healthcare is justified almost all the respondents indicated that interprofessional conflict affects healthcare delivery whilst a similar proportion had also indicated that interprofessional conflict is prevalent in the health sector further details relating to knowledge of interprofessional conflict are presented in fig 2 findings in this study shows that interprofessional conflict places patients at a disadvantaged position as a result of its effect in delivery of healthcare services this can consequently deny patients access to high quality healthcare services only few participants indicated that interprofessional rivalry in healthcare sector is productive and a strong majority of the study participants indicated that interprofessional rivalry is common in the health sector however slightly above a quarter of the respondents agreed that interprofessional rivalry is justified other relevant details about knowledge of conflict in the healthcare sector are presented in fig 3 findings in fig 3 also indicate that a populous proportion of the sample had good knowledge of the negative effect of interprofessional rivalry as they clearly indicated that interprofessional rivalry is unhealthy and unproductive experience of conflict and rivalry a strong majority of the study participants had experienced interprofessional conflict in their practice more than a third of the respondents indicated that interprofessional conflict has retarded their career progression and about a twothirds of the sample indicated witnessing conflict resulting in negative clinical outcome figure 4 provides details of experience of conflict findings from this study therefore suggests high rate of interprofessional conflict among healthcare professionals in nigeria there is need to holistically address the various causes of conflict in order to achieve a peaceful milieu in nigerian healthcare system this is important for the purpose of patients who may be adversely affected by the impact of conflict in the sector a considerable proportion of the study participants indicated that they had experienced interprofessional rivalry in their practice whilst only few participants agreed that interprofessional rivalry has positively influenced their career figure 5 below gives an overview of the study participants experience on interprofessional rivalry in this study findings therefore suggest that interprofessional rivalry is prevalent among healthcare professionals in nigeria addressing the causes of interprofessional rivalry is critical in order to prevent conflict and crises in nigerian healthcare sector further to the descriptive statistical analysis undertaken chi square test was carried out to determine association between variables findings indicate that a strong majority of doctors pharmacists medical laboratory scientists and nurses agreed that they had experienced interprofessional conflict in their practice as compared to only 709 of other healthcare workers not in the above categories this finding was statistically significant similarly more doctors pharmacists medical laboratory scientists and nurses indicated that they had experienced interprofessional rivalry in their practice compared to 74 of other healthcare workers that indicated that they had experienced interprofessional rivalry again this finding was statistically significant also interprofessional rivalry seems to be common in the public sector and least prevalent in development sector as 856 of participants in public sector indicated that they had experienced interprofessional rivalry which was higher than 778 that indicated they had experienced interprofessional rivalry in development sector this finding too was statistically significant discussion findings from this study revealed that salary structure was the most indicated source of conflict in the nigerian healthcare sector suggesting that salary structure has played significant role in interprofessional conflict among healthcare personnel in the country this finding therefore suggests the need for proper harmonisation of salary component among healthcare professionals in nigeria two salary scale exists for healthcare workers with wide disparity between the salary structures 21 the salary systems include consolidated medical salary structure for physicians and dentists and the consolidated health salary structure for all other healthcare professionals proper review and harmonisation of these two salary structures can reduce conflict arising as result of disparity in salary as well as prevent frequency of strike actions in the healthcare sector slightly above twothirds of the study participants attributed leadership of agencies and rivalry as sources of conflict in the healthcare sector thereby corroborating previous study that reported these two components as some of the most common causes of strike in the healthcare sector 22 another source of conflict that closely followed was lack of team work and this is comparable to previous studies that reported lack of collaboration among nigerian healthcare workers unlike what is obtainable in developed countries 23 24 25 the implication of this finding is that patients may not receive high quality healthcare services thereby reducing treatment outcomes adequate collaboration among healthcare professionals can increase quality of care working together as a team reduces medical errors and increases patient safety 26 in nigeria healthcare workers belonging to different groups engage in fight for supremacy the crises that erupt from this process consequently prevents optimal healthcare delivery to nigerians 27 in addition teamwork reduces workloads increases job satisfaction improves patient satisfaction and reduces morbidity 28 furthermore findings revealed that lack of respect disparate entry level and lack of collaborative training at undergraduate level also have considerable effect on causes of conflict among healthcare professionals disparity exists between the entry point of physicians and other healthcare workers whilst healthcare professionals like pharmacists and medical laboratory scientists enters public service at salary grade level 10 the physicians are placed on entry point of salary grade level 12 and this is different from what was obtainable 3 decades ago 29 almost all the respondents in this study indicated that interprofessional conflict and interprofessional rivalry are common in the health sector whilst also accepting that these practices affects healthcare delivery these findings indicate that attaining universal health coverage in nigeria may take longer time if contextual strategies are not developed to mitigate conflict in the health sector as available evidence suggests that crises within the healthcare workforce is a major constraint towards global health system development and sustenance 30 31 32 although majority of the study participants indicated that there is no justification for interprofessional conflict in the health sector up to a quarter of the study participants indicated that interprofessional conflict in the health sector is justified which is a source for concern further studies can be undertaken in this area to understand reasons for this justification about threequarters of the study participants were aware that interprofessional rivalry is not healthy whilst a similar proportion also indicated that such rivalry is not also productive these findings suggest that the participants understood the negative impact of interprofessional conflict and rivalry in the sector in this study findings revealed that a strong majority of the study participants had experienced interprofessional conflict and rivalry thereby validating previous study that reported high rate of interprofessional conflict in the health sector 32 furthermore doctors pharmacists nurses and medical laboratory scientists were more likely to experience interprofessional conflict and rivalry compared to other healthcare workers therefore policy development to address interprofessional conflict and rivalry should be targeted more at these group of professionals so as to achieve the primary obligation of healthcare professionals which is the wellbeing of patients 812 also findings from this study identified public sector as the sector where interprofessional conflict is more likely to be experienced suggesting the need for desperate and urgent reforms to mitigate conflict in this area regarding effect of conflict on career findings from this study indicate that interprofessional conflict had retarded the career of more than a third of the study participants whilst only a few respondents seem to have benefited from interprofessional conflict this also buttress the importance and need to initiate policy reforms that will promote harmonious relationship among healthcare workers successfully achieving this will expedite the development of nigerian healthcare sector to international standard and healthcare personnel in nigeria will be more dedicated to their services 1433 interestingly majority of the study participants were in consensus that they had witness conflict results in negative clinical outcomes which further validates the negative effects of healthcare conflict on patients conclusion this study has revealed a number of insightful findings regarding interprofessional rivalry and conflict in nigerian healthcare sector there is no better time than now to articulate strategies in mitigating and preventing rivalry and conflict in the nigerian healthcare sector interprofessional conflict and rivalry may not only hinder nigerians access to high quality healthcare services but can also result in a wastage of resources for both the healthcare system and patients whilst this study provides evidence that validates existence of interprofessional conflict and rivalry in the healthcare sector other findings that emerged represent an opportunity to develop contextual strategies that can appropriately address rivalry and conflict among healthcare professionals therefore further studies in this area can be focused on articulating robust and comprehensive strategies in preventing rivalry and conflict in the sector • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from authors contributions enam is the sole author of this study the author read and approved the final manuscript competing interest the author declares that there is no known conflict of interest that could have appeared to influence this study

the healthcare workforce is regarded as an essential component of any functioning health system and a lack of optimal collaboration among this group can result to poor quality healthcare services to the population in nigerian setting the health sector is faced with challenges of interprofessional conflict and rivalry this study aimed at understanding knowledge causes and experience of interprofessional conflict and rivalry among healthcare professionals in nigeriaa cross sectional study was undertaken to administer questionnaires to healthcare personnel in various healthcare facilities in nigeria data were analysed using statistical package for social sciences results a total of 2207 valid responses were received and male participants were in majority as indicated by 637 of the sample collectively doctors and pharmacists represented twothirds of the sample and majority of the participants were in the public sector 825 disparity in salary structure was the highest source of conflict whilst almost all the participants indicated that interprofessional rivalry and conflict are prevalent in health sector about threequarters of them 732 disagreed that this practice is productive a considerable number of the respondents had experienced interprofessional conflict and rivalryevidence from this study can help policymakers in developing framework that can be utilised in addressing rivalry and conflict in the healthcare sector

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introduction the pacific islander population is increasing rapidly in the united states the most rapid growth has been in rural southern and midwestern states 12 pacific islanders are underrepresented in health research as prior research has often aggregated data on pacific islanders and asians into one racial category which can obscure health disparities 3 4 5 6 7 8 while there has been limited research on pacific islanders the available data indicate significant health disparities between pacific islanders and other racialethnic populations in the united states 9 10 11 12 13 14 15 16 17 18 for example 237 of pacific islanders surveyed by the centers for disease control and prevention in 2010 reported a diagnosis of type 2 diabetes which is higher than any other racialethnic group estimates of t2d in the marshallese population range from 20 to 50 compared to 83 for the us population and 4 worldwide 19 20 21 22 23 24 25 pilot health screening research with the marshallese community in northwest arkansas documented extremely high incidence of t2d and prediabetes with 90 of marshallese participants being overweight or obese 25 overweightobesity is the strongest modifiable risk factor for t2d 26 and even a weight loss of 5 to 10 of a persons body weight is clinically meaningful and reduces the risk for t2d 27 28 29 the diabetes prevention program is an evidencebased program that has been shown to improve risk factors for t2d including weight eating habits and physical activity and to decrease the incidence of t2d by 58 across multiple settings in the general population and in multiple racial and ethnic populations 3031 recent systematic reviews noted the dpp has yet to be adequately tested in pacific islanders 3132 however a culturally adapted version of the dpp partnership for improving lifestyle intervention dpp affected weight loss albeit modest among native hawaiians and other pacific islanders mainly chuukese living in hawaii 3334 however the effectiveness of the dpp has yet to be tested in pacific islander populations outside of the pacific region and in contexts that could enhance its efficacy until the dpps effectiveness can be confirmed in specific disaggregated pacific islander populations disparities in t2d are perpetuated this paper presents the protocol of a randomized controlled trial designed to compare the effectiveness among marshallese pacific islanders in arkansas kansas missouri and oklahoma of 2 dpp programs a faithbased dpp that was tested in african american churches the wholeness oneness righteousness deliverance dpp 3536 and pili dpp this trial has 2 objectives to contribute to the evidence base for dpp efficacy among pacific islanders and to compare the effectiveness of 2 adapted dppsthe word dpp adapted to include faithbased focus vs the pili dpp adapted to include culture specific focus the project is currently implementing the intervention thus the subsequent description will reflect the studys current timeframe of march 2018 version 1 this study is approved by the university of arkansas for medical sciences institutional review board it is registered at clinicaltrialsg methods study setting the study will be conducted in 32 marshallese churches in arkansas kansas missouri and oklahoma churches are a particularly appropriate setting for dpp intervention delivery in marshallese groups prior needs assessments have shown that 9651 of marshallese report regular church attendance within the marshallese culture churches represent more than religious affiliation they represent the primary social and hierarchical institution in the marshallese community 37 churches often represent clan and atoll affiliation for marshallese migrants pastors and madam pastors have respected leadership roles within the community that are more akin to island chiefs than to american pastors 37 communitybased participatory research partnership this study uses a communitybased participatory research approach because of its demonstrated effectiveness in mitigating barriers perpetuated by historical trauma the marshallese community exhibits distrust in academic researchers that is a byproduct of their experience with us nuclear testing and the unethical scientific study of those marshallese that were exposed to nuclear fallout 38 cbpr approaches provide a way to address the historical trauma experienced by the marshallese by prioritizing research topics chosen by the community and includes the full participation of the community in all aspects of the research by sharing power with community members a cbpr approach builds trust between community members and academic researchers and is an effective way to engage minority participants in research 39 40 41 42 in 2012 a cbpr partnership was formed when uams began working with the marshallese community in arkansas kansas missouri and oklahoma using a participatory process to understand community assets and needs this engagement process is described elsewhere 43 44 45 46 through a 2year engagement process using broadbased mixed methods and multiple focus groups the cbpr team documented the marshallese communitys top priorities that included t2d obesity and culturally appropriate care the cbpr team has conducted several pilot studies related to t2d and obesity beliefs and behaviors 25434447 and a fully powered rct to test a family model of diabetes selfmanagement education 4849 throughout this work community and academic partners have collaborated on planning implementing and disseminating research the current study is based upon a direct request from marshallese pastors to focus on the prevention of t2d and to provide health education in church settings table 1 outlines how core cbpr principles as delineated by israel et al 50 have been used in this comparative effectiveness rct study aims the primary aim of the rct is to compare 2 dpp programsthe faithbased word dpp 3551 and the pacific culturally adapted pili dpp 3352 in the marshallese population using a randomized cluster design the primary outcome is percent body weight loss from baseline weight theoretical framework the projects conceptual framework is based on social cognitive theory 53 and social support and network models 54 both recognize the interaction between individuals their environment and their behavior with social support and network models focusing on the social environmental components of sct both dpp interventions will use sctbased behavioral strategies typically used in evidencebased behavioral weight control programs that will address the physical environment and the individual to cause behavior change sctbased strategies will be complemented with the engagement of social networks within marshallese families and churches building upon these current social networks through implementing a groupbased program within these social institutions is hypothesized to facilitate changes in community or peergroup norms and promote weight loss study design and randomization to assess the comparative effectiveness of word dpp and pili dpp a cluster rct design will be used a total of 384 participants who are overweight or obese will be recruited from 32 churches randomization will occur at the church level with 11 assignment of 16 churches to each arm churches will be blocked according to the geographic region and approximate number of adult church members using a computer generated algorithm for random assignment half of the churches within each block will be assigned to word dpp arm and half will be assigned to pili dpp arm of the study randomization will be conducted by a biostatistician who will have no interactions with potential participants and no supervisory role with study staff responsible for recruitment consent and intervention processes table 1 application of communitybased participatory research principles 4950 cbpr principle application of cbpr principles in the dpp development the community is the unit of identity • marshallese communities in arkansas kansas missouri and oklahoma are the unit of identity and engaged as partners strengths and resources within the community are built upon • the research questionwhether pili dpp or word dpp is more effective in reducing weight and other risk factors for t2dis examined in the larger context of our cbpr work that includes an ecological approach with programs focused on healthy food access cultural training for health care providers and policy reform • the comparative effectiveness design means all participants will receive a dpp intervention an ecological model of health and local relevance of public health problems are emphasized • • addressing t2d was identified by the community as the most important local public health issue from previous formative work 43 • the research is part of the larger policy system and environmental approach that focuses on ecological factors that can help prevent t2d systems development is involved through a cyclical and iterative process • study participant recruitment and screening participants will be recruited from marshallese churches clinics communitybased organizations and social media in arkansas kansas missouri and oklahoma churchbased recruitment was specified by stakeholders as culturally appropriate and the communitys preferred recruitment method the study team has developed strong relationships with 52 marshallese churches in the area and the churches have agreed to work with study staff to inform participants about the study churches will distribute study information and will allow study staff to present information about the study to the entire congregation to ensure that we reach those who do not attend church routinely study information will also be provided through clinics the respective states departments of health communitybased organizations and social media the recruitment goal is 384 participants during recruitment marshallese study staff will give presentations and distribute study information in english and marshallese those who express interest will be invited to complete an eligibility screener questionnaire which will ask about height weight date of birth interest in participation physical limitations related comorbidities and questions regarding their ability to participate in physical activity the data safety and monitoring committee led by an endocrinologist and a marshallese family practice physician will review the results of the screener questionnaire before participants are allowed to enroll participant inclusion and exclusion criteria marshallese adults who have a body mass index of ≥25 kgm 2 will be eligible for the study persons who have a clinically significant medical condition likely to affect weight are currently pregnant or breastfeeding an infant who is 6 months old or younger or those who will not be able to complete the 6month intervention will be excluded from participation all study information and materials will be provided in english andor marshallese according to each participants preferences the consent documents will be orally reviewed with eligible persons in a group and questions answered by marshallese bilingual research staff an opportunity will be provided to all potential participants for individual private discussion of the study and the consent document before they sign the consent a copy of the consent document will be given to the participant and the informed consent process will be documented in the participants research record all members of the research team are trained and certified in participant consent procedures the study protocol and human subjects protection data collection biometric and survey data will be collected at preintervention postintervention and 12month postintervention biometric measures will include measured weight measured height hemoglobin a1c waist circumference and blood pressure participants weight will be measured to the nearest 05 lb using a calibrated scale height will measured to the nearest 025 inch using a stadiometer weight and height will be used to compute a continuous measure of bmi using the quetelet index 55 systolic and diastolic blood pressure will be measured using a sphygmomanometer and stethoscope or digital blood pressure device with the participant seated and arm elevated finger stick blood collection will be used to test hba1c using a rapid a1c test kit and siemens dca vantage analyzer 56 the data collection will be completed by qualified trained research staff bilingual study staff will be present to interpret for participants the survey instruments have been translated into marshallese by a certified interpreter and tested by the studys marshallese community advisory board prior to implementation the survey data collection includes 57 items adapted from valid and reliable scales which will take participants approximately 20 minutes to complete fruit and vegetable consumption will be measured using a questionnaire by shannon et al 57 sugar sweetened beverage consumption will be assessed with items from the behavioral risk factor surveillance system 58 psychosocial variables including social support and selfefficacy for body weight diet and physical activity will be assessed weight locus of control is measured using the weight locus of control scale 59 family support for exercise and healthy diet will be measured by items from gruber 60 exercise selfefficacy will be measured using the selfefficacy for exercise and outcome expectations scale by resnick et al 61 selfefficacy scales for healthrelated diet and exercise behaviors will also be assessed using clark et als 62 measure other variables that will assessed will include food insecurity from national health and nutrition examination survey 63 sleep quality and quantity items are taken from the brfss 58 an item from koenig and büssing 64 will be used to measure church attendance and items assessing how often participants receive health messages at church were adapted from ayers et al 65 in addition to biometric and survey data collection participants will be invited to participate in a qualitative interview at 6months postintervention to understand participants perceptions of the intervention and implementation process the study team will minimize missing data by using highly qualified staff to systematically collect data from all participants the research electronic data capture platform will be used to monitor the occurrence of missing data during field collection 66 redcap has a standard missing data report to facilitate the identification of missing data fields which allows for continuous data quality monitoring so that missing data can be collected immediately if a participant drops out the study team will document why the drop out occurred the study team will continue to collect information on all outcomes from participants unless consent is withdrawn remuneration participants are offered a 20 gift card as remuneration for their preintervention data collection 30 gift card as remuneration for postintervention data collection and 40 gift card as remuneration for their 12 month postintervention data collection participants will only receive gift cards for the data collection events they complete participants who participate in the qualitative interview will be given a 20 gift card intervention description and delivery participants will either receive word dpp or pili dpp based upon random assignment marshallese stakeholders chose these 2 interventions because both interventions were developed through cbpr processes and both have shown effectiveness in other populations 33 34 35 both interventions will be delivered at a church in a group setting both interventions core curricula emphasize selfmonitoring behavioral strategies for weight loss decreasing caloric intake for weight loss and increased moderate physical activity each group will be led by bilingual dpp lay educators who each received at least 40 hours of dpp lifestyle coach training both interventions will offer materials in both english and marshallese both interventions will offer makeup sessions for missed modules the word dpp curriculum is based on an adaptation of the dpp for rural african american communities of faith that utilized a cbpr approach 35 preliminary efficacy data reports that african american participants of word dpp achieved 23 weight loss from baseline to 6month followup participants attending at least half of the intervention sessions lost 37 and 214 of participants lost at least 5 these results are comparable to the dpp studies in african americans 67 for this study community and academic partners revised the word curriculum that was originally designed for rural african american faith communities the curriculum was changed to ensure relevance to marshallese faith communities the word dpp was not adapted for other aspects of marshallese culture such as the collective nature of the family the word dpp includes 16 lessons delivered by trained community members over a 24week period with each lesson approximately 90 minutes in length the first 8 lessons are to be delivered weekly with the last 8 lessons to be delivered biweekly mirroring the core content of the dpp the word dpp emphasizes reduced caloric intake increased physical activity and behavioral strategies for weight loss participants are also taught about the connection between faith and health and the importance of drawing from ones faith to make healthy changes the pili dpp is a twophase family and communityfocused dpp curriculum that teaches participants to engage their family and community supports to achieve a healthy weight eat healthy and be physically active the first phase is a culturally adapted dpp for pacific islanders that includes all of the original core dpp curriculum with the addition of 2 topics on the economics of healthy eating and talking with your doctor 52 the 16 original dpp sessions were condensed into eight sessions and 2 additional topics were included the second phase is an extension of the basic dpp curriculum to include family and friends and to leverage existing community supportsresources to support longterm individual behavior changes specifically participants are asked to elicit support from their friends and family increase family activities around eating and being active manage challenging social situations effectively communicate ones healthy lifestyle goals and identify and utilize community resources this second phase includes an additional 6 lessons for this study pili dpp includes all 14 sessions delivered over a 24week period with each session lasting approximately 90 minutes participants will be encouraged to log their weight physical activity and nutrition on a daily basis the pili dpp has fewer contact hours than word dpp and is culturally adapted with examples relevant to pacific islanders 3352 in prior studies pili has demonstrated significant weight loss and significant improvements in blood pressure and physical activity frequency and decreases in dietary fat 3334 3 data analysis power sample size and detectable effects a cluster randomized design is employed to reduce contamination using the cluster randomized design with church as a cluster unit we will recruit a sample size of 32 churches for an overall sample of 384 individual participants this number of churches and participants achieves 91 power to detect a difference of 25 kg between the 2 groups mean body weight loss from preto postintervention assessment when the intracluster correlation is 001 using a linear model with a significance level of 005 we have 80 power to detect smaller effects if observed 68 69 70 71 72 all power calculations were conducted with pass12 73 statistical analysis plan all of the analyses will be performed with sasstatv141 74 data will be examined for distributional normality and outliers prior to any analyses descriptive statistics will be generated for all variables of interest included in the analysis overall and by intervention assignment univariate comparisons will consist of ttests and anova and chisquare and other nonparametric tests if needed for continuous and categorical variables respectively the distributional assumptions for outcome measures will be examined which may prompt transformations if justified the results of parametric and nonparametric univariate tests will also be compared as a sensitivity analysis to examine the robustness of our findings if distributional assumptions are not met nonparametric tests will be applied extent of randomization will be assessed by comparing intervention arms on baseline measures using ttest chisquare test anova and other appropriate tests if imbalances are found adjusting the betweengroup analyses for potential confounders will be considered primary analyses will be intentiontotreat without regard to intervention adherence multivariable linear ancova regression models for continuous outcomes will be used to account for clustering effect within churches to model and compare pili dpp to word dpp using these models treatment effects will be estimated and tested by comparing change from baseline in groupspecific means at 6 and 12 months postintervention conservatively adjusting for baseline differences and taking into account intracluster correlation by assuming compound symmetry covariance structure the main independent variable of interest is intervention assignment and the primary outcome is percent body weight loss from preto postintervention assessment measures of weight will be obtained at multiple points during the study and changes from preto postintervention and preintervention to 12 months will be modeled in separate models general linear and mixed ancova regression models for continuous measures with clustering will be utilized with the treatment effect estimated as the distance between the fitted groupspecific means at the postintervention assessment while adjusting for the fitted distance between them at baseline in addition conservative adjustments will be made within the model for demographic factors and other covariates listed above in order to model the outcome at the 12month time point a similar model to the one described above will be applied with repeated measures and incorporate intervention assignment time and their interaction effect while adjusting for the same covariates as in the first model this will allow the examination of weight change trajectories over time for both groups secondary outcome measures that are continuous in nature will be modeled using the same approach as for the primary outcome secondary outcomes that are discrete will be modeled using generalized estimating equations for repeated binary measures accounting for the correlation within churches the effect of dosage on outcome variables will be tracked and analyzed to account for missing data imputation methods will be compared under several assumed missing data mechanisms missing at random and missing not at random in order to determine which underlying mechanism best fits the data given recent advances in handling missing data in longitudinal studies several reasonable approaches are available that will be applied and compared the results of the analysis will be compared using 3 approaches as a comprehensive sensitivity check use a random effects model in sas proc mixed that makes use of all available data when assuming observations are mar perform multiple imputations in sas proc mi when assuming observations are mar and perform patternmixture model imputations in sas proc mi when assuming observations are mnar to address this potential source of inferential error monotone regression based multiple random imputations of the outcomes will be used demographic covariates and prior weight measurements that are available in this predictive model will be used the analysis will then be carried out in multiple data sets and the results will combined using standard methods in sas proc mianalyze to produce summary effect and standard error estimates that incorporate the imputation error 7576 we will also determine if aspects of participants built environment as measured by google streetview 7778 and aspects of the food environment based on business analyst in arcgis influence the effectiveness of the intervention 79 plans evaluate heterogeneity of treatment comparative effectiveness of the 2 dpps will also be evaluated among subgroups to determine whether effectiveness varies for specific population segments this will be done by testing 2way interactions between intervention assignment and covariates of interest these include sex age education insurance status and marital status bonferroni corrections will be applied to control pvalues for multiple comparisons for these exploratory comparisons all relevant subgroup outcomes will be analyzed and reported data safety and monitoring this study poses minimal risk the data safety monitoring committee is composed of a marshallese family physician an endocrinologist and a health educator from the marshallese community the data safety monitoring committee reviews for participant eligibility as well as adverse events data sharing plan the study team will construct a complete cleaned and deidentified copy of the final dataset used in conducting the final analyses this data set will be made available to other researchers researchers interested in accessing data will be asked to submit a letter of intent that describes their proposed research the types of data required and a demonstration of adequate expertise to conduct the proposed research the loi also requires information regarding resources available for the proposal funding source equipment and technical support each loi will be reviewed by a committee at uams that includes the principal investigator or a coinvestigator and members of the marshallese community researchers will sign data use agreement to ensure proper handling of the data dissemination plan dissemination is crucial to achieving research impact and benefits for stakeholders academic dissemination will include peerreviewed journals and academic conferences manuscripts will adhere to consort reporting guidelines for cluster randomized trials 80 marshallese community partners will be invited to coauthor and copresent research with the research team and are coauthors of this paper in addition when conducting research to address health disparities there is an ethical responsibility to disseminate findings back to participants and community members the agency for healthcare research and qualitys dissemination planning tool 81 will be used as the framework for dissemination dissemination to study participants results will be returned to participants first each participant will be mailed or emailed a onepage summary of results that is formatted as an infographic the infographic will be presented in english on one side and in marshallese on the other side the infographic will use plain language suitable for all audiences including those with low health literacy the infographic will use culturally relevant picturesexamples this type of infographic is preferred by marshallese stakeholders and has been successfully used during our prior studies to provide results to participants the study team has incorporated careful measures to protect the participants involved in the study aggregate results will be disseminated and no protected health information will be shared in addition participants will be invited to the town hall meeting discussed below dissemination to the broader marshallesepacific islander community a cbpr approach values colearning transparency reciprocity and partnerships therefore it is important to disseminate regular study updates as well as final results to the broader community marshallese stakeholders have expressed a preference for periodic updates on progress throughout the study study updates and final results will be disseminated during biannual town hall meetings that will be hosted by the studys communitybased partner and facilitated by the community coinvestigators at these meetings the research team will present updates on enrollment and retention when the study concludes the results and lessons learned will be presented using an easy to understand infographic as described above marshallese stakeholders use social media as a primary means of communication within the community therefore recruitment information study updates and dissemination of final results will be provided through facebook and other websites only aggregate information without phi will be shared

background pacific islander populations including marshallese face a disproportionately high burden of health disparities relative to the general population objectives a communitybased participatory research cbpr approach was utilized to engage marshallese participants in a comparative effectiveness trial testing 2 diabetes prevention program dpp interventions designed to reduce participants weight lower hba1c encourage healthy eating and increase physical activity design to compare the effectiveness of the faithbased word dpp to the culturally adapted pacific culturally adapted diabetes prevention program pili dpp a clustered randomized controlled trial rct with 384 marshallese participants will be implemented in 32 churches located in arkansas kansas missouri and oklahoma churches will be randomly assigned to word dpp arm or to pili dpp arm methods word dpp focuses on connecting faith and health to attain a healthy weight eat healthy and be more physically active in contrast pili dpp is a family and community focused dpp curriculum specifically adapted for implementation in pacific islander communities pili focuses on engaging social support networks to maintain a healthy weight eat healthy and be more physically active all participants are assessed at baseline immediate post intervention and 12 months post intervention summary both interventions aim to cause weight loss through improving physical activity and healthy eating with the goal of preventing the development of t2d the clustered rct will determine which intervention is most effective with the marshallese population the utilization of a cbpr approach that involves local stakeholders and engages faithbased institutions in marshallese communities will increase the potential for success and sustainability this study is registered at clinicaltrialsgov nct03270436

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introduction advance directives document patients preferences towards endoflife planning based on patient autonomy and selfdetermination ads are designed to protect patient autonomy based on the belief that patients who lose decision making capacity are more likely to receive the care they want if they choose a surrogate decision maker document their wishes in advance or both 1 ads allow patients to choose how they should be treated in the event that they lose the ability to make their own medical decisions absence of ads may lead to unwanted aggressive care after decision making ability has been lost 2 and this unwanted aggressive care has been associated with poorer quality of life and quality of care 3 thus ads are an essential part of comprehensive care near the endoflife 4 however only 20 to 40 of patients in oncology units complete ads on admission 56 completion rate of ads has not even change after the passage of the patient selfdetermination act in 1990 7 and has remained relatively low in usa 8 ads are not actively used in korea 9 where significant proportions of cancer patients receive chemotherapy up to endoflife 1011 furthermore no consensus has been reached regarding effective strategies toward the active use of ads as well as optimal timing for completing ads various issues including lack of information regarding ads 12 negative perception 13 lack of communication 14 and physicians reluctance 1315 could inhibit the implementation of ads hence in order to encourage the use of ads and to devise effective strategies aimed at promoting the completion of ads compressive understandings regarding the attitudes toward ads and endoflife issues by the different people are strongly warranted however to date published studies have focused on the attitudes of patients toward ads 1216 and completion of ads 17 there are discrepancies in attitude toward endoflife care and planning among patients family caregivers and physicians 18 19 20 21 22 few studies have directly compared the attitudes of patients family caregivers physicians and members of the general public toward ads differences in perceptions towards ads would be obstacles toward their institutionalization and incorporation into law for example in usa the federal patient selfdetermination act which aimed facilitating the use of ad seems to fail because the act and policy had not reflected complex issues happened in real medicosocial field 8 accordingly the purpose of this study was to investigate korean attitudes toward ads among cancer patients family caregivers oncologists and members of the general public in addition we attempted to identify factors associated with a favorable perception toward ads and finally we suggest a strategy to encourage the use of ads materials and methods survey a structured questionnaire was developed specifically for this study to explore the attitudes of participants to ads the questionnaire requested the following demographic information age sex relationship to patient level of education income and religion the opinion of the participants regarding necessity of ads the optimal timing of ads necessary items for ads form opinions on the disclosure of terminal status hpc the withdrawal of futile lifesustaining treatment and euthanasia a total of 29 questions were asked to each group for obtaining their opinion regarding not only ads but also overall concept for hpc identical questions were put to cancer patients family caregivers oncologists and members of the general public additional questions concerning experiences of hospice and preterminal care were put to oncologists patients were assured that their responses would not be shared with their oncologists statistics questionnaire responses were compared using the chisquare test univariate logistic regression models were used to test associations with attitudes toward ads multivariate analysis was performed using the forward stepwise procedure to fit a logistic regression model using an entry level of 005 all statistical tests were twosided and significance was accepted for p values of 005 statistical analyses were performed using stata statistical software version 110 results discrepancies in attitudes toward advance directives demographic data were collected from all patients and the characteristics of all 3840 study subjects are summarized in table 1 median age of the study subjects was 47 years and cancer patients were older than members of the other three study groups significant discrepancies in attitudes toward necessity and timing for ads were found between cancer patients family caregiver oncologists and the general public the majority of patients family caregivers oncologists and general public agreed with the necessity of ads in terms of necessary items for ads form more than 95 oncologists answered that items regarding cardiopulmonary resuscitation and mechanical ventilator would be included in ads form and need to be clarified by document in other groups around 70 of subjects answered that cardiopulmonary resuscitation and mechanical ventilator are necessary items for ads form relatively lower proportion of oncologist answered that antibiotics hemodialysis and artificial nutrition are necessary items for ads form regarding the necessary items for ads form there were no significant differences between the three groups optimal timing for the completion of ads also differed by group more than half of oncologists answered that when became terminal status is the optimal time for completing ads whereas only one third of the other groups thought so and 270 of general public answered that optimal timing for the completion of ads is when healthy in addition members of the four groups showed statistically significant but modest differences in terms of the necessary items for ads and the necessity of providing an explanation of hpc univariate and multivariate logistic regression analysis we performed univariate and multivariate logistic regression analysis to identify factors associated with necessity for ads several factors including age education attitude toward terminal illness and attitudes toward hpc were found to be significantly associated with attitudes to ads table 4 presents the multivariable logistic regression model results which were adjusted for multiple factors simultaneously younger age higher education agreement with the disclosure of terminal illness a positive attitude toward the withdrawal of futile lifesustaining treatment a positive attitude toward active pain control in terminal cancer patients and a positive attitude towards hpc were found to be independently associated with necessity of ads logistic regression analysis was also used to identify factors associated with necessity of ads on a groupbygroup basis the observed trends were similar to those found by multivariable logistic regression discussion in this study we found that attitudes toward ads among cancer patients family caregivers oncologists and the general public were significantly different in terms of regarding the optimal timing of ad completion and necessity of items in ads form members of the four study groups also expressed different opinions about ads oncologists and members of the general public were more likely agreed with the necessity of ads multivariate analysis revealed that nine factors including a younger age higher education agreement with the disclosure of terminal illness and favorable attitudes toward active pain control and hpc were independently associated with necessity of ads in our results oncologists tends to regard when became terminal status as an optimal timing for completion of ads while other groups earlier periodswhen healthy or when diagnosed as canceras it more than 95 oncologist answered that cardiopulmonary resuscitation and mechanical ventilator are necessity items for ads form and need to be clarified by document while around 70 of other groups answered so one possible interpretation would be that oncologists seem to expect ads being as a judgment criteria for medical decision while other groups seems to regard ads as a will which containing values about endoflife oncologists and general public groups more often our multivariate analysis results can suggest that the promotion of favorable attitudes toward hpc would influence positively regarding the necessity of ads although ads are important tools that assist cancer patients facing endoflife respecting patients autonomy 4 completion rates are still low 568 in order to implement an ad system successfully we need to comprehensively understand attitudes towards ads and barriers to ads and construct an appropriate strategy based on these findings a number of studies have addressed barriers to the implementation of ads and have identified clinicians reluctance to discuss the topic because of personal discomfort lack of familiarity with suitable alternatives to aggressive treatment lack of time for discussions the belief that patients and families do not want such discussions and the belief that ads discussions are not needed 13151825 alano et al 17 analyzed barriers and factors that influenced the completion of ads and concluded that seven factors predicted ad completion being asked to complete an ad having someone explain the importance of ads the belief that a completed ad would lead to relief from suffering a history of major surgery having never heard of or received information about ads a female gender and age previous studies on attitudes towards ads in patients 1726 family caregivers 27 physicians 2829 nurses 30 and in the members of general public 31 have been reported few studies have addressed the notion that attitudes towards ads differ among relevant population subgroups 32 33 34 sahm et al 34 reported that the patients healthy control nursing staff and physicians did not essentially differ in terms of their attitudes towards ads however three meaningful differences were identified cancer patients more often expressed an intention to write an advance directive most people are unaware of the possibility of appointing health care proxies and patients did not fear abuse by relatives as much as the other groups blondeau et al 32 reported that physicians attitudes towards ads were less positive than patients attitudes which contradicts our results accordingly to our findings oncologists most favored hpc and ads and in general the attitudes of family caregivers and cancer patients coincided this study had several limitations first we conducted the survey in person for patients family caregivers and oncologists but by telephone in the general public which may lessen the validity of the comparisons made facetoface interviewer may observe understandability and reliability more precisely than telephone interviewers however we have given special training to telephone interviewers and we used a model based on an identical study design and identical questionnaires to overcome this shortcoming second we enrolled only korean participants and there is a crosscultural difference regarding ads 35 thus our results have limitation for being generalized to other cultures despite these limitations to our best knowledge this study was conducted using the largest cohort number and it comprehensively identified factors associated with ads in the four study groups in conclusion to make shared decisions regarding endoflife planning we would recognize that attitudes toward ads can differ among patients family caregivers oncologists and members of the general public in addition it was also found that negative attitudes toward futile aggressive care and favorable attitudes toward hpc were independently associated with a preference for ads this study suggests that to reduce difference in attitudes toward ads between each group and to obtain favorable attitude toward hpc might be considered a cornerstone strategy for the implementation of ads programs and facilitating ad use in addition comprehensive social movement including institutional innovation policy interventions public education and professional guidelines might be warranted or odd ratio ci confidence interval a deathbed is a special room for a patient who refuses cardiopulmonary resuscitation or intensive care unit in order to have death with dignity as patients wishes

purpose the purpose of this study was to investigate korean attitudes toward advance directives ads among cancer patients family caregivers oncologists and the general public methods a multicenter survey study explored the attitudes of participants to ads and hospicepalliative care hpc was conducted a total of 1242 cancer patients 1289 family caregivers 303 oncologists and 1006 members of the general public participated in the survey

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university of pittsburgh pittsburgh pa usa sponsored by nih grants r37ag023651 and r01ag05854901 objective health disparities between communities with greater and lesser advantages are a global concern in the usa selfidentified race as african american is consistently associated with mild cognitive impairment and dementia compared to americans of european descent in a prospective populationbased study we sought to confirm this association and investigate potential explanatory factors methods the monongahelayoughiogheny healthy aging team and seniors project 15104 studies recruited adults aged 65 years from a group of small towns of lower socioeconomic status in the us myhat recruited by agestratified random sampling from the voter registration list for all towns sp15104 recruited by intensive community engagement from three towns with populations that are 60 aa based on the clinical dementia rating mci was defined as cdr05 and dementia as cdr 1 using cox proportional hazard models we modeled time to incident cdr 05 from baseline as a function of race other demographics and several other covariates at baseline results the sample of 2120 individuals was 8 aa and 62 female with median age of 73y and median educational level of partial college during follow up of up to 145 years 499 participants developed newonset mcidementia cox models revealed that being aa was significantly associated with incident cdr 05 inclusion of age sex and education in the model increased the hr for race to 163 adding number of regularly taken prescription drugs depression symptoms preceding year alcohol consumption and number of visits to emergency or urgent care together reduced the hr to 14 no longer statistically significant conclusions in this populationbased cohort study selfidentified african americans had an about 40 elevated risk of developing mcidementia adjusting for demographics the significant association between race and incident mcidementia was attenuated by variables reflecting depression greater general morbidity and lesser access to regular health services these variables possibly reflect downstream effects of historic discrimination but couldstill be modifiable risk factors for mcidementia addressing them could potentially mitigate ethnoracial disparities in cognitive impairment background telehealth has been an important method of health care delivery during the pandemic particularly for older adults who have been more vulnerable to the physical and psychosocial impacts of the pandemic and associated isolation older adults have specific medical and mental health care needs that would benefit from having access to geriatric speciality services however these services may be difficult to access especially for those living in rural areas though the use of technology and telehealth has greatly expanded during the pandemic

in canada adults 85 years and older represent one of the fastest growing segments of the population 1 mood disorders and chronic illness often intersect worsening health outcomes in late life 2 in view of demographic trends medical schools should ensure trainees are equipped with the knowledge skills and attitudes to work with older adults however there continues to be much variation in how medical schools incorporate geriatric content into their curricula in 2009 the canadian geriatrics society cgs outlined 20 competencies in geriatrics to inform medical school curricula but uptake was minimal of note there were significant gaps in these competencies which omitted mention of latelife depression geriatric mental health experts did not provide input the objective of this project was to address gaps in geriatric competencies for medical students through an expert review process involving a biopsychosocial approachthe cgs established a 15member national working group with representation from geriatric psychiatry family medicine a 95yearold senior geriatrics and medical trainees potential competencies were derived from existing canadian geriatrics frameworks geriatrics 5m canmeds and 2009 competencies a modified delphi process yielded rankings for each competency using a 7point likert scale results between 2019 and 2021 3 successive national surveys were completed in the first n66 34 competencies were identified agreement in the final survey was 8795 mean 90 51 participants completed all three significant topic omissions in the 2009 list of competencies were frailty endoflife care delirium prevention health promotion and the assessment and management of depression conclusions three national surveys expanded the core competencies in geriatrics for medical school curricula from 20 to 31 expert consensus was high themes mapped along existing geriatrics frameworks and incorporated a holistic lens incorporating the perspectives of an older adult and geriatric psychiatrist in addition to latelife depression the importance of addressing ageism was also highlighted learning objectives for each competency are modifiable for level of training and individual program offering flexibility the cgs will continue to advocate for inclusion of updated expanded competencies into training and licensure in geriatrics

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introduction sustainable development was first proposed by the brundtland report in as development that meets the needs of the present without compromising the ability of future generations to meet their own needs it aims to balance the global linkages between issues of environmental degradation socioeconomic problems associated with inequality and poverty and the needs of future generations however the concept of sustainable development cannot be used directly as a tool for addressing these global issues as it has a certain vagueness to solve global problems that are halting sustainable development it is necessary to operationalize this concept and transform it into related specific goals and precise action plans in 2000 the un proposed the first set of operationalized goalsthe millennium development goals which was designed to address global issues such as ending poverty ensuring food accessibility and improving health of these goals socioeconomic problems rather than environmental issues were the main focus in 2014 the un put forward the second set of operationalized goalsthe sustainable development goals which was designed to replace the mdgs and designate the un agenda until 2030 as a new global agenda for promoting sustainable development the sdgs not only inherited the commitments of the mdgs that focused on addressing socioeconomic issues but also concentrated on issues related to governing the earth system and reducing the unsustainable practices of individuals groups and countries more specifically the sdgs consist of 17 goals ending poverty and hunger promoting wellbeing and quality education achieving gender equality ensuring sustainable water and affordable energy promoting decent work and inclusive industrialization reducing inequalities between countries building sustainable cities and encouraging sustainable consumption combating climate change conserving marine life promoting sustainable ecosystems and inclusive societies and revitalizing global partnerships these goals articulate definite needs for the international community to build a sustainable future and were adopted by all countries in 2015 current literature on the sdgs has primarily focused on the content analysis of these goals the principles that should be followed when implementing these goals and the integrated dynamic method to evaluate the implementation effectiveness of these goals although these research efforts are important for making sdgs implementation more effective it is also important to understand individuals perception of these goals and gain their support to help transform these goals into specific and actual actions furthermore as the sdgs are a proposed agenda that will expire in 2030 individuals who commit to implement the sdgs may focus more on actions with immediate outcomes and less on actions with benefits that will only become salient after 2030 therefore making progress in building a sustainable future requires both individuals immediate support for the sdgs and a longterm commitment by individuals to the needs of future generations however the previous literature on sdgs has not investigated what might affect individuals perception of the current sdgs and what might motivate individuals to go beyond the sdgs to care for the needs of future generations as reminders of death can influence attitudes motivation and behavior in various aspects of our lives in this paper we thus explored whether reminding individuals of their own death will influence their perceived importance of the sdgs and intergenerational altruism when facing the choice between fulfilling the needs of the current generation and those of future generations according to terror management theory humans are caught in a paradox on the one hand humans are similar to other species with a strong biological tendency for selfpreservation and continued existence on the other hand humans are different from other animals in that they have sophisticated cognitive abilities that make them aware that life is temporary and transient and they will inevitably die 1 day this coexistence of the desire for immortality and awareness of their mortality can induce existential anxiety this anxiety can be alleviated by creating a sense of literal or symbolic immortality to either deny or transcend ultimate death therefore when reminded of ones own death individuals need ways to help them feel a sense of immortality and defend against existential anxiety one way individuals can buffer existential anxiety is through culture it enables individuals to believe that they are significant and enduring beings in a world of meaning rather than merely animals only doomed to death culture functions as an anxiety buffer consisting of two components one is the worldview which provides a meaningful and stable conception of reality the other is selfesteem which is the belief that one is living up to the norms values and standards advocated by their culture according to tmt when mortality is made salient individuals are motivated to adhere to their cultural worldviews and believe they are valuable and meaningful within their own culture in line with this reasoning empirical evidence has shown that when reminded of their mortality individuals are more likely to validate their specific cultural worldviews and show greater favoritism toward their ingroup members meanwhile priming death awareness increases peoples prejudice toward others who hold different cultural worldviews and motivates aggression toward outgroup members another way individuals can defend against existential anxiety is by denying that humans are a part of nature it releases humans from the realm of a mortal nature and offers the hope that human existence is not simply temporary and death can be transcended thus according to tmt when primed with mortality salience individuals become motivated to distinguish themselves from the rest of nature and show negative attitudes toward nature or animals to facilitate their denial of mortality this logic is supported by research for example koole and van den berg showed that death reminders reduced the perceived beauty of wilderness goldenberg et al suggested that as individuals become conscious of their own mortality they are more likely to support the belief that humans are distinct from animals moreover they are more likely to disconnect themselves from other animals and treat animals as resources commodities and valued goods that benefit human beings mortality salience not only motivates individuals to behave in ways that are consistent with social norms in their own culture but also induces individuals to follow the values or norms that are made salient by specific contexts thus the effects of mortality salience on attitudes and behavior depends on whether a specific value norm identity or worldview is salient taking environmental protection for example mortality salience causes individuals to be less concerned about the environmental impact of land development unless they derive selfworth from their environmental actions proenvironmental behavior that reduces waste of resources such as using reusable instead of disposal cups is induced by mortality salience only when a proenvironmental norm is salient in addition perceptions of existential threats result in decreasing biocentric motivation and biospheric concern when environmental identity is low and for individuals who hold a conservative environmental worldview mortality salience does not enhance any collective ecoguilt even when these individuals realize the failure of society to meet proenvironmental standards in comparison when those individuals who strongly endorse environmental values have those values made salient mortality salience increases ecoguilt in addition intergenerational altruism could serve as another way to repress deathrelated anxiety the reason behind this rationale is that intergenerational altruism extends individuals existence into the future and helps them to achieve the goal of symbolic immortality by facilitating a psychological connection between the self and others in the future and establishing a legacy to create a lasting impact on others this rationale was supported by the research of wadebenzoni et al who found that when making intergenerational decisions about donating money and allocating resources priming death awareness can trigger individuals legacy motivations and lead them to donate more money and allocate more resources to others in the future while the prior research has examined the impacts of mortality salience on individuals reactions to ingroup and outgroup members humannature relationships environmental protection and intergenerational decisions in terms of donating money and allocating resources to future others we do not yet know whether mortality salience affects individuals perceived importance of the sdgs and intergenerational decisions in terms of caring for the needs of future generations the purpose of this paper therefore was to explore the effects of mortality salience on individuals perceived importance of the sdgs and intergenerational altruism materials and methods a survey embedded randomized control experiment was conducted to test the effects of mortality salience on intergenerational altruism and the perceived importance of the sdgs the experiment was conducted in august of 2016 participants were recruited from the online survey platform amazon mechanical turk samples collected via mturk have been widely used in numerous survey and experiment studies all participants indicated informed consent electronically were guaranteed anonymity and allowed to discontinue the study at any time the study was reviewed and approved by the ethics review committee of nankai university design and procedures this study used a onefactor betweensubject experimental design participants were told that the study consisted of several short and independent parts part a which was actually the experimental manipulation section introduced a mental simulation task participants were randomly assigned to one of the following three experimental conditions mortality salience condition neutral condition and dentist visit condition in the mortality salience condition participants were asked to think of their own death in the future by responding to two questions with no time limit briefly describe the emotions that the thought of your own death arouses in you and jot down as specifically as you can what you think will happen to you as you physically die and once you are physically dead this manipulation is adopted from greenberg et al in the neutral condition participants were asked to describe a typical grocery shopping experience in their lives writing about grocery shopping has been used as a control condition in other areas of research following the suggestion of the previous literature on mortality salience we included a comparison condition of dentist visit to rule out an alternative explanation that the effect of mortality salience on our dependent measures was caused by the negative mood associated with death thoughts specifically we asked participants in the dentist visit condition to think about the experience of seeing a dentist by responding to two questions with no time limit briefly describe the emotions that the thought of going to the dentist arouses in you and jot down as specifically as you can what do you think will happen to you physically at the dentist as previous research has found that levels of negative affect are similar when one thinks about visiting the dentist vs when one thinks about death including this dentist visit condition can help us further identify the unique effect of mortality salience immediately after that the mental simulation task all participants reported their momentary mood on the most widely used for measuring affective experience the positive and negative affect schedule scale it is a 5point scale and consists of 10 items that measure positive mood and 10 items that measure negative mood then all participants entered part b a word search puzzle used as a filler task for the mortality salience manipulation the participants were asked to find and write down at least three words that were hidden in an 8 × 7 matrix the task which required about 1 min to finish was added to create a longer delay because prior research suggests that a longer time delay between the mortality salience manipulation and the dependent measures is associated with a larger effect of mortality salience finally ostensibly as a third unrelated part c all participants responded to the questions that measured their attitude toward intergenerational altruism and the perceived importance of the sdgs the detailed measures are presented in the next subsection demographic information was collected at the end of the survey including age gender education attainment race whether they attended religious service or not whether they had children or not whether they worked in a hospital or not and subjective socioeconomic status dependent measures our dependent measures included two parts the first part was to measure intergenerational altruism specifically all participants read a text that said sustainable development has been defined as development that meets the needs of the present without compromising the ability of future generations to meet their own needs it often embraces a triple bottom line combining the interest of the present generation and the interest of the future generations however sometimes there are competing priorities in your opinion whose needs should be given higher priority participants were asked to make a choice between two options a the needs of our current generation b the needs for future generations the second part measured the perceived importance of the 17 sdgs all participants first read a brief introduction to the sustainable development agenda and the 17 sdgs as follows the united nations announced an agenda for sustainable development last year following an inclusive process of intergovernmental negotiations as a plan of action this agenda will be implemented by all countries and stakeholders the agenda consists of 17 sustainable development goals which are listed below then participants were asked to indicate how important they think each of these goals was on 5point likert scales the order of the two dependent measurements was counterbalanced as order of presentation had no effect on our results we did not include this variable in the subsequent analyses results effect of mortality salience on mood to examine whether mortality salience affects participants positive and negative moods and rule out mood as an alternative explanation for our effects we separately conducted two oneway anovas for positive mood and negative mood the results showed that there was no significant difference for the three experimental conditions in terms of positive mood f 036 p 070 η2 p 0002 but there was a significant difference for negative mood f 926 p 001 η 2 p 006 pairwise comparisons using bonferroni method suggested that when compared to the neutral condition a significant difference in the participants negative mood was produced by both mortality salience condition t 355 p 001 and dentist visit condition t 390 p 001 however there was no significant difference in the participants negative mood between the mortality salience and dentist visit conditions t 01 p 099 these results suggest that there was increased negative mood in the mortality salience condition compared to the neutral condition however the negative mood in the mortality salience and the dentist visit conditions were not significantly different this similar level of negative mood in the mortality salience and the dentist visit conditions allows us to examine the specific effects of mortality salience by comparing these two conditions effect of mortality salience on intergenerational altruism a chisquare test was conducted to examine the effect of experimental conditions on intergenerational altruism the result showed that the experimental conditions had a significant effect on the participants judgment regarding the priority between the needs of the current generation and the needs of future generations χ 2 626 p 004 cramers v 015 pairwise comparisons using partition of chisquare method indicated that making mortality salient caused a higher percentage of participants to place a higher priority on the needs of future generations when compared to the neutral condition χ 2 611 p 0013 2 however it did not induce a significantly higher percentage of participants to place a higher priority on the needs of future generations when compared to the dentist visit condition χ 2 268 p 0101 in addition priming the dentist visit when compared to the neutral condition did not significantly increase the percentage of participants who chose the needs of future generations as a greater priority χ 2 069 p 041 detailed information on these result are shown in table 1 below consistent results were produced by using binary logistic regression to investigate the effect of mortality salience on intergenerational altruism factor analysis and the effect of mortality salience on the perceived importance of the sdgs while the 17 sdgs were combined as an idea serving the political agenda of building a sustainable future it is unclear whether these goals also converged as one factor or not in the minds of the participants thus we performed an exploratory factor analysis to further explore the underlying relationship between these 17 sdgs following the recommendations of costello and osborne we first selected principle axis factoring as the factor extraction method since some of the sdg items such as ending poverty gender equality and combating climate change had negatively skewed distributions then we chose direct oblimin rotation instead of varimax rotation method as we expected the underlying factors to be correlated the result yielded two factors with the eigenvalues 1 and a high correlation coefficient of these two factors justifying the rotation approach we chose the first unrotated factor accounted for 4908 of the total variance and the second unrotated factor accounted for an additional 370 of the 17 sdgs 12 items loaded on the first factor with weak crossloadings on the second factor while 5 items loaded on the second factor with weak crossloadings on the first factor as the 12 items in the first factor predominately related to social issues and the 5 items in the second factor were associated with ecological issues we labeled them as the socially related sdgs and the ecologically related sdgs respectively to examine the effect of mortality salience on the perceived importance of the socially related sdgs and the ecologically related sdgs we created two indexes by averaging the scores of their respective items then two oneway anovas with each factor as a dependent variable were performed separately the results showed that the experimental conditions had a significant effect on the perceived importance of the socially related sdgs f 446 p 001 η 2 p 003 and a marginally significant effect on the perceived importance of the ecologically related sdgs f 298 p 0054 η 2 p 002 pairwise comparisons using bonferroni method for the perceived importance of the socially related sdgs indicated that participants in the mortality salience condition had a significantly lower mean than those in the dentist visit condition t 256 p 003 and those in the neutral condition t 260 p 003 however participants in the neutral condition and those in the dentist visit condition did not significantly differ in the perceived importance of the socially related sdgs t 01 p 099 similar pairwise comparisons for the perceived importance of the ecologically related sdgs showed that participants in the mortality salience condition did not significantly differ from those in the dentist visit condition t 182 p 021 but they had a marginally significant lower mean than those in the neutral condition t 230 p 0053 further participants in the neutral condition and those in the dentist visit condition did not significantly differ in the perceived importance of the ecologically related sdgs t 045 p 099 to facilitate the interpretation of the results figure 1 illustrates the effects of experimental conditions on the perceived importance of the socially related sdgs as well as the ecologically related sdgs additional analyses additional analyses were performed to explore whether any of our measured demographical variables influenced the observed effects percentages in the rows without a common subscript differed at p 005 between conditions figure 1 the effects of experimental conditions on the perceived importance of two factors of the sdgs error bars represent 95 confidence intervals the effect of gender was first examined3 a 2 × 3 anova on the perceived importance of the socially related sdgs indicated a significant main effect of experimental conditions f 472 p 001 η 2 p 008 a significant main effect of gender f 2395 p 001 η 2 p 008 and a marginally significant interactive effect of gender and experimental conditions f 282 p 006 η 2 p 002 simple effects analyses showed that the perceived importance of the socially related sdgs among the three conditions were significantly different for men f 720 p 001 η 2 p 008 but they were not significantly different for women f 013 p 088 η 2 p 0001 further pairwise comparisons with bonferroniadjusted method revealed that men under the mortality salience condition perceived the socially related sdgs as significantly less important than men under the dentist visit condition t 321 p 001 and the neutral condition t 329 p 001 however men under the dentist visit and the neutral conditions did not differ significantly in the perceived importance of the socially related sdgs t 004 p 097 a similar anova on the perceived importance of the ecologically related sdgs showed a significant main effect of experimental conditions f 310 p 0046 η 2 p 004 a significant main effect of gender f 1076 p 001 η 2 p 004 and a marginally significant interactive effect of gender and experimental conditions f 248 p 009 η 2 p 002 simple effects analyses indicated that the perceived importance of the ecologically related sdgs among the three conditions significantly differed for men f 470 p 001 η 2 p 003 but they did not significantly differ for women f 061 p 054 η 2 p 0004 further pairwise comparisons with boniferroniadjusted method suggested that mortality salience induced men to perceive the ecologically related sdgs as significantly less important compared to the neutral condition t 313 p 001 but there was no significant difference when compared to the dentist visit condition t 131 p 018 in addition men in the dentist visit condition perceived the ecologically related sdgs as marginally significantly less important than men in the neutral condition t 167 p 0095 the effects of other variables including race whether the participant had children or not whether the participant worked in hospitals or not religious service attendance education attainment and subjective socioeconomic status were also investigated these results suggested that none of these factors had main and interactive effects on the perceived importance of the socially related sdgs and the ecologically related sdgs discussion this paper explored the effects of mortality salience on intergenerational altruism and individuals perceived importance of the sdgs we found that mortality salience induced participants to care more about the needs of future generations only when compared to the neutral condition we also found mortality salience reduced participants perceived importance of the socially related sdgs when compared to both the dentist visit and the neutral conditions and mortality salience decreased participants perceived importance of the ecologically related sdgs only when compared to the neutral condition effect of mortality salience on intergenerational altruism our research revealed that when compared to the neutral condition mortality salience can promote intergenerational altruism our research also indicated that participants in the mortality salience condition did not significantly differ in their prioritization of the needs of future generations compared to those in the dentist visit condition although the current study does not provide conclusive evidence for the unique effect of mortality salience on intergenerational altruism the fact that the percentage of participants who chose the needs of future generations was the highest in the mortality salience condition is suggestive the reason behind this potential positive effect of mortality salience might be that acting on behalf of future generations helps individuals achieve the goal of outlasting their own existence thereby repressing deathrelated anxiety our finding was consistent with the research of wadebenzoni et al which showed that mortality salience motivates individuals to behave generously to benefit future others when compared to the control condition however there are two differences between our research and their paper in terms of research design first their paper asked participants to make intergenerational decisions such as donating money and allocating resources between present and future others but we directly asked participants to choose whether the current or the future generations needs should be a higher priority second their paper included only two conditions in our design we added a dentist visit condition our research by using an alternative measurement and a threecondition design provided partial support for the argument that intergenerational altruism might serve as a way for individuals to buffer anxiety when they are reminded of their own mortality and somewhat extended the effect of mortality salience on selfprotective altruism to intergenerational altruism effect of mortality salience on the perceived importance of the sdgs as for the effect of mortality salience on the perceived importance of the sdgs our results showed that mortality salience reduced the perceived importance of the socially related sdgs when compared to both the dentist visit and neutral conditions a potential explanation for this negative effect of mortality salience might be that individuals want to support their own worldview and not follow the global agenda because the global agenda might blur the cultural differences that make each culture unique when perceiving the importance of those sdgs that seek to solve global social issues and promote global benefits the participants who were american in our study might have seen these goals as infringing on their own cultural worldview and freedoms consequently the perceived importance of the socially related sdgs was reduced when participants were reminded of their own mortality this finding partially echoed the research of jonas et al which showed that mortality salience increased participants tendency to help poor people but only for those in the participants own country in other words mortality salience had no effect on helping outgroups when ingroups and outgroups were distinguished however as shown in our research mortality salience had a negative effect on the perceived importance of social issues that included helping others when ingroups and outgroups were combined this result may contribute to the literature that suggests reminders of mortality increase negative evaluations toward outgroup members or dissimilar others our results also indicated that mortality salience led to marginally significant reductions in the perceived importance of the ecologically related sdgs when compared to the neutral condition however it should be noted that participants in the mortality salience and the dentist visit condition did not significantly differ on the perceived importance of the ecologically related sdgs although these results do not provide conclusive evidence for the unique effect of mortality salience on the perceived importance of the ecologically related sdgs the fact that the perceived importance of the ecologically related sdgs was the lowest in the mortality salience condition is suggestive the potential negative effect of mortality salience on the perceived importance of the ecologically related sdgs can be explained by the reasoning that separating humans from nature could make individuals uphold their belief that they are not subject to the natural laws of death and decay the ecologically related sdgs included cues of wild animals and nature which may remind individuals of their own biological identity and mortal nature as a result when mortality was made salient and participants were asked to perceive the importance of the sdgs that aim to protect endangered animals and the natural environment they would deny their creatureliness and perceive the ecologically related sdgs as less important in addition our results revealed that gender and experimental conditions produced marginally significant interactive effects on the perceived importance of the socially related sdgs and the ecologically related sdgs specifically mortality salience led men to perceive the socially related sdgs as significantly less important than men both in the dentist visit and the neutral conditions this result suggested that gender moderates the effect of mortality salience on the perceived importance of socially related sdgs mortality salience also caused men to perceive the ecologically related sdgs as significantly less important than men in the neutral condition but not in the dentist visit condition thus this result only provided partial support for a potential moderating role of gender on the effect of mortality salience on the perceived importance of ecologically related sdgs the moderating role of gender may be explained as follows men tend to hold less universalistic values and proenvironmental attitudes when men are reminded of their mortality they may become more entrenched in their worldview and their perceptions of the importance of the socially related sdgs and the ecologically related sdgs decrease limitations and future directions despite the efforts made in this research there are limitations that can potentially be addressed through further research as mentioned above the effects of mortality salience on attitudes motivation and behavior involving ingroup vs outgroup members may differ and the effects of morality salience may depend on the activation of specific norms and values future research could examine the moderating role of individuals group identity and selftranscendence values on the effect of mortality salience on the perceived importance of the sdgs in addition as implementing sdgs may require large government investment and incur debt in the present time individuals who are more conservative in their political ideology may view achieving some of these sdgs as potentially burdening future generations thus the political orientation of individuals should be investigated as a potential moderator in future research moreover our results might have been influenced by individuals perceptions of the un specifically individuals who do not like the un may not support plans proposed by the un and may have given less importance to these sdgs so it is also important to explore whether changing the fact that the un is the source of these goals will make our results different in terms of manipulations our priming of mortality salience only asked the participants to write down their thoughts of death future research could improve on this method by implementing field experiments in special event situations that will potentially remind people of their mortality furthermore writing about the experience of grocery shopping touched on issues like food security accessibility and availability and thinking about visiting the dentist involved issues related to health these two writing tasks might influence individuals perceived importance of those sdgs that focus on food security and healthy lives so future research might utilize different comparison conditions to try to replicate our results as for the measurement of intergenerational altruism it was a binary choice while this choice is straightforward future research could operationalize this concept through simulated decision scenarios with regard to sample selection participants in this study were recruited from mturk and lived in the united states future research should recruit participants from different countries to test whether and how individuals with various cultural worldviews perceive the importance of the sdgs in similar or different ways in addition we did not identify whether the participants in our study had been exposed to similar experimental manipulations before further research could check whether the mturk workers who participated are naïve to mortality salience research and whether previous experience might affect their responses on the outcomes of interest supplementary material the supplementary material for this article can be found online at 201801399full supplementarymaterial conflict of interest statement the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

the sustainable development goals sdgs consisting of 17 specific goals such as ending poverty reducing inequality and combating climate change were proposed by the un member states in 2014 for the ongoing un agenda until 2030 these goals articulate the growing need for the international community to build a sustainable future to progress and build a truly sustainable future requires not only the immediate support of individuals for the current sdgs but also their personal longterm commitment to the needs of future generations ie intergenerational altruism reminders of death can influence attitudes motivation and behavior in various aspects of our lives in the current research we thus explored whether reminding individuals of their own death will influence their intergenerational altruism and perceived importance of the sdgs using a threecondition mortality salience vs dentist visit vs neutral randomized experiment we found that mortality salience led participants to place a higher priority on the needs of future generations only when compared to the neutral condition further we conducted a factor analysis that generated two sdgs factors socially related sdgs and ecologically related sdgs we found that mortality salience reduced participants perceived importance of the socially related sdgs when compared to both the dentist visit and the neutral conditions and mortality salience decreased participants perceived importance of the ecologically related sdgs only when compared to the neutral condition

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i introduction criminal responsibility is experiencing something of a moment in historicized studies of law sociohistorical scholarship on criminal responsibility which has developed in part in critical dialogue with the legalphilosophical scholarship that still dominates the field has now come to form a vibrant domain in its own right like other work in the sociohistorical scholarly tradition this scholarship subjects criminal responsibility principles and practices to analysis in light of the substantive social political and institutional conditions under which these principles and practices are given life 1 this approach has generated deep insights into criminal responsibility scholars working in the sociohistorical tradition chart the dynamic relationship between ideas about criminal responsibility and the development of the modern state2 the changing coordination and legitimation requirements of criminal law into the current era3 the role of the police power 4 and the influence of enlightenment liberalism on the structures and operation of the criminal law 5 these accounts reveal the complex and nonlinear ways in which individual responsibility for crime has become the central organizing principle of the criminal law in the current era in order to build on existing sociohistorical scholarly work on criminal responsibility this article explores the social dimension of responsibility for crime and presents one way in which it might be examined in concrete terms by the social dimension of responsibility for crime i refer to the way in which criminal responsibility practices refract social norms around responsibility 6 as their name implies sociohistorical scholars are particularly interested in the social dimension of responsibility for crime as nicola lacey argues criminal responsibility is an idea which is located within a social practice of holding individuals to account and the social intellectual and institutional environment within which legal ideas emerge influences the way legal rules are developed and applied 7 alan norrie suggests that in criminal law individual responsibility is always intermixed with social responsibility for wrongdoing 8 finding concrete ways to examine the social dimension of criminal responsibility practices has not proved straightforward however as lacey notes in relation to conceptual accounts of criminal responsibility the connection between the account and broader social ideas and institutions too often slips out of view 9 and for sociohistorical scholars who are aware of the significance of the social in criminal responsibility translating this awareness into specific research projects has proved challenging 6 see celia wells i blame the parents fitting new genes in old criminal laws 61 mod l rev 724 wells argues that the mixed audience to which they are addressed and the mixed aetiology of the sorts of cases which enshrine principles of criminal law ensure that they refract rather than reflect cultural ideas of responsibility id at 735 as this suggests the ideas of responsibility presented in the criminal law are mediated by the institutional and other aspects of the context in which those ideas are developed 7 see nicola lacey institutionalising responsibility implications for jurisprudence 4 jurisprudence 1 1011 8 see alan norrie simulacra of morality beyond the idealactual antinomies of criminal justice in philosophy and the criminal law principle and critique 117 9 see lacey supra note 7 at 4 how might we move beyond invocation of the significance of the social dimension of criminal responsibility to examine it in concrete ways one way to explore the social dimension of responsibility for crime is to adopt social rather than legal units of scholarly analysis by this i suggest taking a unit of analysis that differs from traditional legal units of analyses which typically concern acts that can be committed by anyone while there are multiple examples of social units of analysis that might be of interest in sociohistorical and critical legal study 10 it is notable that sociohistorical scholars typically borrow standard doctrinal or theoretical units of analysis for sociohistorical inquiry there is however a good reason to adopt different units of analysisit opens different ways of thinking about criminal responsibility studying a social category or group cuts across familiar legal categories and presents a way of tapping broader currents of meaning around responsibility for the empirical study presented in this article i adopt the social category of exsoldiers or war veterans exsoldiers are a particularly apt social group for the study of criminal responsibility for two main reasons first they are a distinctive and privileged group and in the australian context enjoy a high profile over the course of the twentieth century war has loomed large on the australian social landscape and it has proved to be important in australias selfunderstanding both popular and scholarly 11 war has played a crucial role in development of australian national identity and was integral to the project of nation building in the period after the end of the colonial era 12 australian experiences of war in the twentieth centuryworld war i world war ii korea vietnam and iraq and afghanistanand other military engagementssuch as east timorhave varied significantly but despite declining numbers of active military personnel fewer military casualties and scant public support for war or overseas deployment of australian troops the social status of returned service men has remained high 13 second veterans are a particularly apt social group for the study of criminal responsibility because as former agents of the state they bring the state into the criminal courtroom in distinctive ways in the modern era of mass soldiering in an age of total war 14 soldiers are a group set apart from others licensed to kill on behalf of the 10 eg simon bronitt wendy kukuliessmith crime punishment family violence and the cloak of legal invisibility 37 j austl stud 390 11 see generally richard white war and australian society in australia two centuries of war and peace 390 susanne davies women war and the violence of history an australian perspective 2 violence against women 359 12 eg ks inglis the anzac tradition 24 meanjin q 25 graham seal inventing anzac the digger and national mythology on gender and nationbuilding see stephen garton war and masculinity in twentieth century australia 22 j austl stud 86 marilyn lake mission impossible how men gave birth to the australian nationnationalism gender and other seminal acts 4 gender hist 305 13 see davies supra note 11 14 see martin crotty mark edele total war and entitlement towards a global history of veteran privilege 59 austl j pol hist 15 state which otherwise enjoys a definitional monopoly on violence 15 this complicates the standard criminal law dynamic of state versus individual and opens the way for different and more complex responsibility dynamics to appear this article offers an analysis of the criminal legal treatment of men who having been in the military and in some cases having served in war face serious criminal charges after returning home to australia the cases examined in this study span the period of the twentieth century the cases comprise reported and unreported criminal trials appeals and sentencing hearings in which the defendant was identified as an exsoldier 16 neither military justice cases nor civil cases are included in this study 17 my research indicated that there were a number of decisions in which the defendants military or war service was mere background to his or her trial or sentencing and did not appear to have played a real role in evaluation of the defendant 18 this was the case even when the military service resulted in the defendant developing posttraumatic stress disorder 19 in the majority of cases however military or war service was considered by the court to be relevant in some way as my study reveals military or war service has multiple effects in criminal adjudication and evaluation practices and such effects vary over time and place in some trials military or war service relates to claims of mental incapacity and thus to defenses that go to criminal responsibility in some sentencing decisions military or war service is considered in relation to good character and interacts with other factors such as age guilty pleas and remorse premised on the status of veterans as a distinct social category exsoldiers are accorded special treatment in criminal adjudication and sentencing practices to reflect this special status i label them veteran defendants a legal status arising from the social meanings of war soldiers and soldiering as i discuss in this article the specialness of veteran defendants centers on the exsoldier as a complex figure simultaneously agentic and victimlike courageous and vulnerable both more and less than other defendants i suggest that the special status of veteran defendants has two substantive dimensions veteran defendants as übercitizens civic models or exemplars to whom gratitude is owed 15 see generally mary kaldor new and old wars organized violence in a global era 16 my research generated over 55 written trial records see appendix this is likely to be an underestimate of cases involving returned servicemen as the largest jurisdictions the local court and the district court dealing with minor offenses do not produce written records 17 as elsewhere in australia the military justice system is sui generis and runs parallel to civilian systems for an overview see gabrielle appleby the new australian military court a fair go for defence force personnel the conversation in relation to the civil cases a number were brought by or against the department of veterans affairs regarding matters such as entitlements and who generate some form of responsibility in others involved in the evaluation and adjudication process and as individuals with diminished capacity whereby veteran defendants have impaired or reduced responsibility for crime these two substantive dimensions of the specialness of veteran defendants are underpinned by a formal quality of veteran defendantsas seethrough subjects both more known and more knowable to the criminal law than other defendants there is a historical interplay between the two substantive dimensions of the specialness of veteran defendants with the latter becoming more prominent over time as over the course of the twentieth century ideas about war soldiers and soldiering have changed in this article i present my study of veteran defendants in three parts in parts ii and iii i discuss the two substantive dimensions of the criminal legal treatment of returned servicemen that i suggest capture the special status of the veteran defendant in criminal lawthe idea of the individual veteran as an übercitizen and the idea of exsoldiers as legal persons with diminished capacity in part iv i discuss the formal quality of veteran defendants that underpins each of these two substantive dimensions of specialness veteran defendants as seethrough subjects i conclude with a brief discussion of the implications of my analysis for scholarly study of criminal responsibility at this point a note of explanation about my use of the term criminal responsibility is useful i use the term criminal responsibility broadly to denote the dynamics of the processes of blaming and holding individuals accountable 20 in studying criminal responsibility i seek to set these dynamics of blaming and holding individuals to account in their wider institutional and procedural context taking into account sentencing decisions as well as adjudication for instance as a result i am as interested in the language arguments and reasoning used in the courtroom as i am in the substantive outcomes of the decisions discussed here 21 my approach stretches across categories and distinctions typically taken for granted in criminal law theory while scholars tend to take the building blocks of the study of criminal responsibilityresponsibility and liability conviction and sentencing character and capacity defenses and mitigation and punishment and treatmentto be separate and distinct i proceed on the basis that there is value in resisting the neat grooves into which some scholarly thinking on criminal responsibility has settled ii veteran defendants as übercitizens in this section of the article i outline the first of the two substantive dimensions of the criminal legal treatment of returned servicemen that i suggest captures the special status of veteran defendants this is the idea of the individual veteran as a übercitizen a civic model or exemplar to whom gratitude is owed and who generates some form of responsibility in others involved in the evaluation and adjudication process here while war or military service may be regarded as part of the defendants good character 22 the multiple ways in which such service is considered in the courtroom overspill any one legal technology such as good character thus through a rather nuanced notion of gratitude for service and allegiance to the state the defendants status as a returned soldier may go so far as to affect the way in which the offense reflects back on the defendant himself altering the understanding of the crime or allowing the conduct to be described as out of character for the individual as i discuss below veteran defendants as übercitizens transcends the boundary between trial and sentence and seems to have been most prominent after wwi becoming less prominent over the course of the twentieth century this idea of veteran defendants as übercitizens is evident in the decision of r v goldrick handed down by the nsw supreme court in 1924 goldrick had pleaded guilty to embezzlement on the basis of stealing from his employer several times over a period of six months because he had stolen money on several occasions the trial judge did not give him the benefit of the sentencing discount available to first time offenders charged with minor offenses on appeal the court held that the nature of the offense the circumstances in which it was committed and the defendants status as a returned soldier who had undoubtedly during the course of his war service displayed conspicuous gallantry and devotion to duty 23 warranted an extension of the sentencing discount to him while this decision is a sentencing appealthe conviction was neither challenged nor questioned and its clear that the supreme court was acting within the bounds of its discretionthe offense was effectively reconstructed for the purposes of sentencingas a singular minor offensein part on the basis of the defendants veteran status the ethos imbuing this sort of case is an idea of exceptionalitybased on the distinct and privileged social status of australian soldiers in australia returned servicemen became a distinct social group over the twentieth century it is possible to detect this idea of exceptionality early in the twentieth century in relation to soldiers who had served in the colonial wars 24 but wwi was a watershed moment producing what historians have called the citizen soldier 25 coming not long after federation in 1901 wwi was regarded as the moment of the birth of the australian nation soldiers all of whom were volunteers were looked upon in quasireligious light as 22 see r v watson st r qd 6 10 reflecting english common law in australian criminal systems good character evidence may be relevant at trialto suggest that the defendant did not commit the offenseand at sentencingas mitigation see generally nigel walker sentencing theory law and practice 418 23 r v goldrick 24 nsw st r 396 399 24 eg a veteran soldier in want brisbane courier sept 15 1900 at 14 25 see patricia grimshaw et al creating a nation 209 see also id at ch 9 as these authors explain the equivalent identity for women was the citizen mother id at 209 anzac legends whose sacrifice had given birth to the nation 26 it is notable that it was during wwi that the returned soldiers and sailors imperial league of australia which later became the returned and services league of australia was formed to advocate for the special interests of australian servicemen since wwi the rssilarsl has performed this task on the basis of the enhanced citizenship status of its members 27 in the aftermath of wwi soldiers special and privileged status was not only reflected in their treatment in court in decisions such as goldrick but in the development of a welfare scheme specifically for veterans the development of such a scheme was premised on a sense of state and collective responsibility for the fate of exsoldiers after the end of the war which points to the way in which the construction of veteran defendants as übercitizens creates some form of responsibility on the part of others the australian states welfare scheme was multifacetedit included a gratuity for all who served in the war a pension scheme for the dependents of soldiers killed or disabled in war land grants for which only veterans were eligible loans to purchase war service homes and special access to education and training 28 the specialness of veteran defendants with diminished capacity was also evident in this scheme during wwi a split emerged in asylum care in which returned servicemen were quarantined from civilian patients either in separate wards or separate hospitals this separation reflected both the stigma attached to mental illness and the more deserving status of mentally ill veterans 29 as well as the idea that mentally ill servicemen might infect the civilian population 30 separate treatment for mental soldiers was part of the welfare scheme which gave effect to the privilege of citizen soldiers the veteran welfare scheme was both expensive and farreaching and profoundly shaped australian economic and social development in the interwar period australian welfare was extended after wwii when all families became eligible for benefits such as child endowment and the widows pension 31 the notion that gratitude should be extended to veteran defendants on the basis of their demonstrated allegiance and service to the state seems to have been rather nuanced this is evident in the distinction between volunteers and conscripts sharply drawn in one queensland decision in r v byers in 1942 the queensland court of appeal had to consider whether byerss 25 years suspended sentence for the drunk driving deaths of three road workers was adequate 32 the trial judge had taken into account that the defendant had been called up was reported to be a very good soldier and would be received back into his military unit if not sentenced to imprisonment 33 the appeal court was split about the propriety of this reasoning in particular whether a conscript was entitled to the same consideration as a volunteer and the appropriateness of the noncustodial sentence webb cj held that i n these terrible days when the services of every man must be used to the best advantage if the nation is to survive the trial judges decision should be left undisturbed 34 but douglas j held that service in the army however meritorious does not justify a suspended sentence for a serious offense 35 similarly philip j agreed that the sentence should be quashed and a custodial sentence substituted stating that while a volunteer or someone who has undertaken active service is entitled prima facie to some leniency from the state when he offends against its laws a conscript is not so entitled 36 while the fact that this was a wartime decision seems significant the distinction drawn between volunteers and conscripts suggests that those who shouldered the burden of military service voluntarily enjoyed the highest esteem as übercitizens another illustration of veteran defendants as übercitizens is provided by the more recent south australian decision of r v hicks 37 hicks had served in the army in wwii and been stationed in darwin northern territory when it was under attack from the japanese and later in new guinea and had sustained physical injuries he was charged with causing death by dangerous driving having killed two people in another car and was sentenced to two years imprisonment hicks appealed his sentence on the basis that the personal or subjective factors of his case meant he should have been subject to the more lenient provisions of the offenders probation act 1913 the appeal court allowed the appeal stating that hicks had to be given full credit for his service to his country in time of war 38 according to the chief justice who gave the leading judgment a ctual exposure to prolonged danger to life in the course of service to ones country must in my view carry special weight in the sentencing process 39 although the 32 r v byers st r qd 277 33 extracted in id at 28283 34 id at 27879 35 id at 284 36 id at 286 byerss suspended sentence was quashed and he was sentenced to nine months imprisonment with hard labor instead 37 r v hicks 45 sasr 270 38 id at 278 the court of appeal upheld the sentence of two years imprisonment but reduced the nonparole period from 12 months to 6 months 39 id at 285 appeal court had no particular details of hickss service the leading judgment concluded that it can be inferred that he volunteered his services for his country went to areas where he was sent and was subjected to the potential risks of action in notoriously adverse conditions and climate 40 here this list of what are presented as logical or necessary inferences from military servicebeing willing to step up a sense of obedience or duty and braveryare transformed into indicia of good character for criminal legal purposes a further example of veteran defendants as übercitizens to whom gratitude was due is provided by the decision of r v allpass in 1993 41 the defendant was a wwii veteran and had been captured by the germans and held as a prisoner of war for three and half years allpass pleaded guilty to the sexual assault of a nine year old girl and the trial judge deferred passing sentence requiring instead that allpass enter into a recognizance of 5000 to be of good behavior for five years the crown appealed the sentence on the basis of inadequacy but the appeal judges denied the appeal affirming that it was appropriate to take into account allpasss previous unblemished character and his impressive record of war service 42 similarly in r v chapman the trial judge took into account the fact that the defendant who had a gambling addiction and pleaded guilty to a charge of defrauding the commonwealth of more than 274000 had given a lifetime of service to the army and had attained a degree of excellence in his service 43 the appeal court declined to adjust the sentence as is to be expected the gratitude due to veteran defendants as civic models or exemplars extended only so far and claims for special treatment did not always result in an outcome favorable to the defendant in r v lindsay the defendant was unsuccessful in arguing that his sentence was manifestly excessive because the judge had failed to recognize sufficiently that lindsay served in vietnam having been conscripted without attempting to avoid that obligation 44 the appeal court declined to vary the sentence after lindsay had pleaded guilty to drug supply and other related offenses because the sentencing judge had adequately taken into account war service which according to the court had to be weighed against the need for deterrence of this kind of offense 45 as these cases indicate character proved a useful legal technology for accommodating war or military service which was regarded as part of the defendants good character 46 in some instances however veteran defendants overdetermined this legal technology an illustration of this overdetermination is provided by r v pgm which 40 id at 278 41 r v allpass 72 a crim r 561 564 42 id at 566 the appeal court considered the noncustodial sentence unduly lenient but declined to intervene to alter it 44 r v lindsay 2004 qca 444 45 id the court concluded that the allowance made for matters in lindsays favor was adequate was decided in 2008 47 pgm was convicted of multiple counts of sexual assault and indecent assault of a child and sentenced to 7 years imprisonment with a nonparole period of 45 years the prosecution appealed on the basis that the trial judge had wrongly classed the offenses as lowrange and given unwarranted weight to the defendants prior good character the trial judge had referred to the defendants history of volunteer work and involvement with other vietnam veterans as positive evidence of his contribution to the community and an indication that he was a community minded citizen 48 the trial judge concluded that the offenseswhich took place over a number of monthswere out of character for the defendant 49 with this conclusion veteran defendant status operates to eclipse the offenses themselves however in this instance the appeal court disagreed with the trial judge it granted the appeal and held that the judge was not warranted in according prior good character very significant weight because that failed to recognize that the conduct was a determined and conscious course of offending 50 the übercitizen dimension of the specialness of veteran defendants was particularly prominent when the defendant had received awards or commendation for his military service or when his service had been otherwise exemplary indeed in r v hicks discussed in detail above the court lamented the absence of more concrete and specific submissions about the defendants war record apparently on the basis that this would readily justify special treatment 51 the court stated that the services rendered by each servicemen or group of servicemen differed in quality and duration in some cases of exceptional valour or serious injury society owes them much while in other cases in which service was not greatly different from that of numerous civilians at home society owes them less 52 such evidence was available in the decision of r v evans in which the defendant pleaded guilty to several charges relating to a violent robbery that took place on an australian navy ship 53 in rejecting the prosecution appeal against manifest inadequacy of sentence the court noted that evans was commended for his courage and exemplary conduct in the finest tradition of the navy evidence that formed the basis for the sentencing judges conclusion that the crimes were out of character 54 the court noted that although the offense involved a breach of trust against the navy evans was strongly supported by serving members including a commanding officer who gave his view that evans still had a lot to contribute to society 55 the construction of veteran defendants as übercitizens creates some form of responsibility on the part of others involved in the criminal adjudication and evaluation process from my study it is apparent that it is judges who assume this responsibility for responsibility in apportioning responsibility between broadly the state who sent veteran defendants to war or benefited from their military service and the individual who committed the offense judges were engaged in an informal but meaningful weighing up of the weight of the sacrifice made by the veteran defendant on the one hand and the seriousness of the offense on the other as chief justice king put it in r v hicks discussed above w hen a returned serviceman offends against the criminal law and society demands that he be punished that serviceman is entitled to credit proportionate to the service which he rendered to it in time of war 56 in this balancing task it is judges who must resolve any tension between giving effect to the specialness of veteran defendants and at the same time ensuring that no impression was given that because a man has been to war he should be in any way privileged to commit an offence 57 this was a difficult task because as connoted by the concept of status veteran defendants were different from other defendants and their adjudication and evaluation at law seems to threaten to overwhelm neat legal technologies for instance of good character in this part of the article i have made the case that veteran defendants are constructed as übercitizens in and through criminal legal responsibility ascription practices while a couple of the decisions discussed in this section date from the late twentieth and early twentyfirst century the broad historical trajectory of cases in which veteran defendants are constructed as übercitizenscivic models or exemplars to whom gratitude is owed and who generate responsibility in others involved in the criminal evaluation and adjudication processis a downward one this decline seems to be associated with the rise of the idea of veteran defendants as legal persons with diminished capacity to which i now turn iii the diminished capacity of veteran defendants in this section i outline the second of the two substantive dimensions of the legal treatment of returned servicemen that i suggest captures the specialness of veteran defendants the idea of exsoldiers as legal persons with diminished capacity as having impaired or reduced responsibility for crime because their actions were in some sense caused or determined as i discuss in this section of the article the construction of veteran defendants as legal persons with diminished capacity emerges when war trauma is 55 id 24 56 r v hicks 45 sasr 270 285 57 see r v goldrick 24 nsw st r 396 401 regarded as a contributory cause in the commission of the offense 58 or otherwise mitigates the offending again the idea of exsoldiers as legal persons with diminished capacity overspills legal categories such as particular mental incapacity defenses and affects the criminal legal treatment of veteran defendants in various ways to reflect change over time in this part i present what i am suggesting about veteran defendants as legal persons with diminished capacity as two points on a continuum mental soldiers i and mental soldiers ii to convey looser and tighter versions of the idea that war causes crime and that the conduct of veteran defendants is in some sense determined 59 in broad terms from my study the transition from the first to the second of these two points on a continuum corresponds to the period of the vietnam war a mental soldiers i alongside the idea of the soldier as anzac legend that appeared even before the end of wwi another cultural figure emerged the nerveshattered returned soldier or the mental soldier mental soldiers were regarded as peculiar weak in character morally unreliable troublesome or even dangerous 60 these soldiers were regarded as failed anzacs because they had either been unable to stand the heat of battle or they were cowards who lacked the moral fibre to stay in the trenches and face the enemy 61 the mental trauma caused by wwi was encapsulated in the term war neurosis or shell shock a loose term which captured a range of mental and emotional symptoms 62 as a simple concept that allowed those on the home front to grasp the distant horrors of war shell shock captured the public imagination 63 in a way that paralleled other developments in psychological knowledge the concept of shell shock constructed a thoroughly social phenomenonthe emotion associated with trench warfare death and dyingas a disease 64 this disease and the war trauma it connoted were significant factors in the association between war and crime as it provided a ready explanation for criminal conduct and reduced responsibility as i discuss below 58 r v watson st r qd 6 10 59 the term mental soldiers was coined by larsson shattered anzacs supra note 29 to describe the effects of war on soldiers but i use it here in a sui generis way to capture the idea of the diminished capacity of veteran defendants 60 larsson shattered anzacs supra note 29 at 157 61 id at 15960 62 see kate blackmore the dark pocket of time war medicine and the australian state 19141935 at 143 63 see elizabeth nelson victims of war the first world war returned soldiers and understandings of domestic violence in australia 19 j womens hist 83 8889 64 blackmore supra note 62 at 145 on the basis that conditions like hysteria neurasthenia and cowardice were blamed on the individual blackmore concludes that the range of disabilities attributable to war was partly determined by the way the war itself had been defined id at 149 the specter of the mental soldier on the postwwi landscape was part of a wider recognition of the negative effects of the war on individual soldiers and the communities to which they returned even before the end of wwi major australian newspapers were spotted with stories about the downfall of exservicementhose who had been charged with serious offenses or who had turned to drink 65 in 1919 soldiers rioted in sydney and melbourne 66 and the 1920s saw growing popular and official or governmental awareness of the soldier problem with alcohol 67 historians have suggested that police juries and magistrates were sympathetic to returned soldiers at least up to point 68 nonetheless newspaper commentary conveyed concern about the attitude that unrulinessbrawling and boozingwas part of being a good soldier 69 and in the 1920s there was a jump in arrest rates indicating a short sharp intensification of personal conflict that accompanied the return of servicemen 70 and in the interwar period exservicemen came to dominate mens prisons and asylums 71 mental soldiers were the subject of considerable governmental consternation this was reflected in debate about the aetiology of shell shock although the concept of shell shock generally enjoyed expert and popular acceptance during and after wwi there was widespread discussion in australia about whether shell shock cases were the result of war trauma or whether they reflected predisposition or hereditary weakness the then popular theory of predisposition influenced the attitudes and practices of military psychiatrists and others who placed the blame for nervous conditions squarely on the shoulders of the soldier affected 72 as kate blackmore argues the indeterminate nature of shell shock meant that in army doctors assessments responsibility for it could be readily transferred to the individual solider making him ineligible for the army pension 73 to avoid any implication that war caused illness military and government personnel used terms such as anxiety state and prohibited the use of the term shell shock an approach selfconsciously designed to discourage fabrication and ensure such a diagnosis was unheroic and generally undesirable in turn enabling the government to minimize the costs of dealing with incapacitated veterans 74 from my study it is not clear whether in the years after wwi the debate about the aetiology of shell shock extended to the courtroom or to what extent the conduct of veteran defendants with shell shock was judged to be caused or determined 75 but there is other evidence to indicate that mental soldiers were treated sympathetically when they came to the attention of the courts having been charged with offenses 76 in her close study of arrest rates and trials for violent and sexual offenses against women judith allen concludes that the heroes of the first world war received recognition in criminal justice responses to violence against women 77 and based on her close examination of cases of nonfatal violence against women elizabeth nelson argues that exsoldiers readily raised war trauma to explain or mitigate allegations of violence at home 78 nelson suggests that generally in public fora such as courts such explanations were not questioned as juries and judges proved willing to accept that returned soldiers could not control themselves under stress or drink and thus that mens violence was an involuntary action 79 as this suggests war trauma readily enabled a legal reading of the conduct of veteran defendants as determined the tendency to blame individual mental soldiers rather than the war itself persisted after wwii a period marked by significant continuities in psychiatric knowledge from the postwwi period 80 from my study in the first decades after wwii suggestions in court that military or war service produced mental soldiers were greeted with some resistance an illustration is provided by the 1955 decision of r v pepper which concerned a wwii veteran charged with two counts of indecent assault of a boy of about fifteen years of age the appeal court refused to alter the sentence of two years imprisonment despite accepting that the offenses could be traced to a state of mind affected by some mental upset in the army the appeal court concluded that this mental upset was secondary to the nervous upset of his early unfortunate upbringing 81 while it seems 74 see muir supra note 30 75 my own study did not identify any cases of wwi veterans who were constructed as having diminished capacity and thus at this point i rely on research of others 76 newspaper reports include reference to trials for minor crimes at which war neurosis was considered relevant eg war neurosis and crime sydney morning herald dec 4 1946 at 4 77 allen supra note 68 at 155 78 see nelson supra note 63 at 9095 79 id at 99 80 see stephen garton fit only for the scrap heap rebuilding returned soldier manhood in australia after 1945 20 gender hist 48 that the specter of homosexuality as perversion colors this judgment it captures a more generalized idea that mental soldiers were considered to be predisposed to such a nervous state prior to their combat experience some returned servicemen defendants were regarded with greater sympathy even if factors other than war service were considered significant causes of their criminal conduct in reg v simpson decided in 1959 the defendant was convicted of manslaughter and sentenced to three years imprisonment for killing another army warrant officer who had begun an irregular association with simpsons wife 82 the court observed that having just been diagnosed at the military hospital as suffering from an anxiety state his wifes departure produced a serious emotional upset in the defendant 83 simpson had had a long and honourable career and been commended in the highest terms by his commanding officers but according to the court even giving fullest weight to the factors personal to the defendant the sentence was inadequate 84 more recently in r v logan the court dealt with a young defendant who had pleaded guilty to unlawful possession of a weapon and break and enter having committed an offense with an army mate 85 at trial logan was sentenced on the basis that at the time of the offense he was suffering from ptsd and major depression after harrowing and horrifying experiences serving in east timor and treated leniently by the court because as a result of the peculiar and necessary bonding and mateship encouraged by the army he felt obliged to help his cooffender 86 on appeal the nsw court of appeal reiterated that this was indeed an exceptional case in which leniency was warranted and the prosecution appeal against manifest inadequacy of sentence failed 87 another category of veteran defendants whose conduct was depicted as caused or determined comprised those veterans who having been traumatized in war had come to selfmedicate with drugs and alcohol in a way that prefigures the stronger causal relationship between war and crime discussed below where successfully used in mitigation these servicemen demonstrated some nexus between the offending the trauma and selfmedication thus even if a veteran defendant had sought refuge in drugs and alcohol as a result of trauma while in military service evidence that the offending was for financial gain meant such a history would not greatly assist him 88 in tran v r the defendant pleaded guilty to supplying heroin and because of the quantity was sentenced to the maximum penalty of twenty years imprisonment the sentencing judge had accepted that 82 reg v simpson 76 wn 589 592 83 id at 593 84 id at 594 the sentence was increased to five years imprisonment by the appeal court tran had been using drugs to selfmedicate after his traumatic experiences in the vietnam war 89 in this instance however the sentencing judge did not accept that the offense was the result of drug addiction as it involved some planning 90 similarly in headley v the queen the defendant had pleaded guilty to several counts of drug manufacture and possession 91 in appealing sentence on the grounds of severity the defense argued that headley a vietnam veteran who had been diagnosed with ptsd had become addicted to amphetamines in dealing with his total physical incapacitation and that he became involved in the offenses primarily to fund and provide for his own use of the drugs 92 the appeal court held that these matters had been adequately taken into account by the sentencing judge and declined to reduce the sentence b mental soldiers ii the second of the two points on the continuum regarding veteran defendants as legal persons with diminished capacity mental soldiers ii captures the stronger causal relationship between war and crimethe idea that war itself is criminogenic an idea that rose to prominence in the decades after the vietnam war as i discuss in this subsection from my study significant war trauma and a tight nexus between the trauma and the offending provided strong grounds for claims of exculpation and mitigation this idea of veteran defendants as legal persons with diminished capacity whose conduct is in a significant way determined is particularly strong for veterans of the war in vietnam as was the case elsewhere the vietnam war was deeply controversial in australia and the effect of the conflict on individual soldiers became the subject of strong popular interest evident for instance in media commentary 93 the combination of the specifics of that conflict and both contemporaneous and subsequent developments in psychiatric knowledge readily produced a veteran with diminished capacity that is a defendant with reduced responsibility for crime for instance in r v mawson the defendants ptsd and acquired brain injury arising from his service in vietnam formed the basis of his plea of diminished responsibility to the charge of murdering a family friend a plea accepted by the prosecution 94 in sentencing mawson the nsw supreme court referred to him as one of the walking wounded stating that although his wound could not be seen it was deep it was permanent it was painful it profoundly changed his personality and it was 89 tran v r 2006 nswcca 266 90 id 12 the appeal against sentencing severity was allowed on another ground 91 headley v the queen 2004 wasca 88 92 id 22 24 41 93 eg war creates crime wave sydney morning herald may 20 1984 at 31 suffered in the course of doing his duty for his country 95 the court accepted that mawsons disorder resulted in increased vigilance perception of threat and a tendency to return to states of mind associated with former trauma and that his criminal responsibility was substantially impaired 96 mawsons sentence was moderated to reflect his war service which had had such a catastrophic effect on him 97 while mawsons disorder affected him in the requisite way in other cases veteran defendants were held to have retained their cognitive and volitional capacities despite the effects of trauma occurring during war or military service in r v lange the defendant raised insanity in response to multiple charges of wounding aggravated robbery and attempted murder having held a neighbor prisoner in an attempt to obtain money 98 the court accepted langes argument that his experience fighting in an australian army mercenary group in vietnam had caused ptsd depression and cognitive impairment 99 but the court held that while his conduct may have been explicable by reference to these impairments lange remained in control at the time of the offenses and carried out a purposeful and directed course of conduct with the motive of obtaining money to buy alcohol 100 as a result the presumption of mental capacity was not displaced and lange was not able to raise an insanity defense as the decisions of both mawson and lange suggest in cases in which veteran defendants raised mental incapacity defenses the court exhibits significant concern with the aetiology of the defendants condition a concern which echoes the expert concern with the causes of shell shock discussed above in relation to ptsd preoccupation with aetiology in part reflects the clinical definition of ptsd in which uniquely aetiology is a component 101 it also reflects a longstanding concern with the boundaries between doctrines such as insanity and intoxication that has troubled the treatment of mental incapacity in criminal law 102 but in addition this concern reflects the 95 special status of veteran defendants because it is war or military service that sets these individuals apart from other defendants making them veteran defendants as mental soldiers the aetiology of their disorder is an essential component of their claim to special status it appears from the cases that courts are alive to the possibility that war trauma might be blamed for the diminished capacity of veteran defendants when it was most properly sheeted home to personal failings for instance in a case involving a defendant who had been convicted of two counts of rape and appealed his continuing detention order the court expressed doubt about the defendants own account of his experience in afghanistan and lebanon with reference to the expert evidence tendered in court the court found that the defendant was intelligent and calculating and not unaware of the benefit which might accrue to him from a diagnosis of ptsd 103 this led the court to cast doubt on the expert psychiatric diagnoses of personality disorder and thus the defendants need for treatment the court rescinded the continuing detention order to which the defendant was subject and ordered a supervision order 104 similarly in the queen v goodwin the queen v mcgregor the appeal court declined to reduce mcgregors sentence for drug trafficking and possession on the basis that it was open to the trial judge to conclude that mcgregor was seeking to avoid all responsibility for the offenses by attributing his conduct solely to his vietnam war service which had resulted in ptsd 105 the sentencing judge had observed that mcgregors complaints about how his life had been changed by the war were tinged with selfpity and selfindulgence and concluded that the defendant could not take further refuge behind his war service and acquired physical and psychiatric conditions 106 the strongest claims for the idea that veteran defendants had diminished capacity and reduced responsibility for crime arose when exsoldiers claimed to have had a flashback to the war or to be in some state of derealization at the time of the offense one of the most important australian cases on the doctrine of automatism concerned a defendant who had served in vietnam and who later killed a person he believed was his wifes new partner when he was in what he alleged was an automatistic state 107 there was expert psychiatric evidence to the effect that the defendants state of depersonalization or disassociation was brought on by emotional stress and that when the killing was committed by the defendant he believed he was in combat and accompanied by another soldier 108 similarly in r v walsh in 1991 the defense raised insanity in response to the defendants murder charge on the basis that walsh suffered from a delusional belief that he was in korea defending himself from an enemy soldier at the time he killed a fellow veteran 109 department of veterans affairs files and medical files indicated that walsh had been diagnosed with war neuroses and anxiety neurosis as early as 1965 110 the jury rejected the insanity defense and on appeal the court held that the defendants delusions should have been considered as part of the circumstances relevant to the question of whether the accused was acting in selfdefense the exception to the sympathy with which cases of diminished capacity were regarded is those cases in which military training and service appeared to enable veteran defendants to commit a particular crime more effectively for example in the queen v king the defendant was charged with several offenses including assault and unlawful imprisonment which followed a violent siege of his landlord and her property 111 both the sentencing judge and appeal court accepted that the offenses were committed when king was suffering from ptsd that followed his involvement in an accident while serving in the australian defence force in somalia but each concluded that the fact that king said he did what he did in a professional military fashion in a wartime situation indicated lack of remorse 112 in this case the individual agency and skill associated with military training and service seems to have undercut and indeed to have been incompatible with any claim to diminished capacity when evidence of war trauma or warinduced mental illness was insufficiently strong to ground a defense like insanity or diminished responsibility it could still be taken into account in sentencing mental soldiers in some of the cases in my study the evidence of the mental health effects of war was merely part of a standard sentencing inquiry into how the defendant would experience prison 113 in other cases war trauma or warinduced mental illness was considered to have only a limited mitigating effect for example in r v osullivan it was acknowledged that the disruptive effect of war service might make it hard for someone to adapt to civilian life but this was considered inadequate for substantial mitigation 114 similarly in r v simpson the defendants ptsd and depression which followed his service in vietnam were regarded as mitigating but as he was charged with two counts of indecent assault and gross indecency and such offenses are not uncommonly committed by persons of good character these factors were considered to be of limited weight 115 in other cases evidence of war trauma or warinduced mental illness had strong mitigating effects meaning the veteran defendant was readily regarded as having diminished capacity in the queen v el aridi in which the defendant had pleaded guilty to trafficking and possession of heroin the court held that all the circumstances of the casesevere posttraumatic stress from service in the war in lebanon and loss of members of his family in that warreduced his culpability and made him an inappropriate subject for general deterrence 116 similarly in r v kennedy the court stated that the defendants mental illness resulting from his exposure to terrible events in vietnam meant less weight was given to the principle of general deterrence in sentencing kennedy for several counts of sexual assault 117 as these last extracts indicate in some cases the special treatment of veteran defendants with diminished capacity as mental soldiers is expressly linked to rationales for sentencing but as i discuss below it is only in a few cases that such rationales are expressly identified by the courts this feature of the legal treatment of veteran defendants relates to another dimension of their specialness to which i now turn iv veteran defendants as seethrough subjects the third and final perspective through which i outline the specialness of veteran defendants is a formal rather than substantive dimension of that specialness in that it relates to the form or shape of the category of veteran defendants rather than the substantive meaning according to veteran defendants this is the idea of veteran defendants as seethrough subjects more known and knowable to the law than other criminal defendants here i suggest that the construction of veteran defendants as seethrough subjects means that veteran status eclipses the person of the defendant such that part of his individuality is hidden behind his veteran identity each of the two substantive dimensions of the seethrough quality of veteran defendants that i discuss below rests on the knowability of veteran defendants which itself rests on a particular type and quantum of information being made available to courts as mentioned above there are a couple of cases involving veteran defendants in which sentencing rationales are expressly referenced in sentencing decisions found in my study 118 both the reduced relevance of general deterrence for mental soldiers and the belief that serving military personnel who have already sought to mend their ways are considered to be more likely to be rehabilitated seem to hint at the special status of veteran defendants but somewhat counterintuitively i suggest that it is the general absence of express reference to sentencing rationales in cases involving veteran defendants that provides the strongest evidence of the seethrough status of this cohort the general absence of express references to sentencing rationales in the cases suggests that it is not sentencing law that explains these decisions but rather something more dependent on social and cultural norms with the effect that the case of veteran defendants is rendered sui generis with judicial references to standard sentencing consideraconsiderations less relevant than might otherwise be the case as i have suggested in this article this is the idea of the specialness of veteran defendants a legal status premised on the social meanings of war soldiers and soldiering the idea of veteran defendants as seethrough subjects means that veteran status eclipses the person of the defendant such that some part of his individuality is hidden behind his veteran identity the knowability of a particular veteran defendant is based on his or her membership in a status group and as a result what functions to make such individuals knowable to the criminal process also operates to obscure this is the case even in sentencing the part of the criminal process in which it has been argued the individual is recontextualized having been decontextualized for the purposes of conviction 119 the specificity of the individual veteran before the court is to some extent subsumed beneath more generic aspects of his status as a veteran defendantunderstood via currents of bravery honor loyalty and service or sacrifice harm injury and trauma according to dynamic social ideas about war soldiers and soldiering some evidence of the seethrough quality of veteran defendants is apparent in the enumeration of collateral costs of punishment for particular defendants 120 the decision of r v t provides an illustration of this aspect of the effect of military service t who was in the air force at the time of the hearing was charged with and pleaded guilty to multiple counts of sexual assault of his daughter when she was aged between 5 and 12 years in this case although the leading judgment noted that the otherwise good character of perpetrators of these offenses provides cover to conceal the criminal acts the judge concluded that the seriousness of the defendants loss of his gratuity and retirement benefits was given insufficient weight by the sentencing judge for the majority it was significant that the defendant could have denied the charges ensuring which the defendants good start at rehabilitation was thought to be connected to the highly disciplined environment of the australian defence forces that the proceedings would not be finished before t had completed 20 years of service and been entitled to claim his benefits 121 according to justice allen the payments due to t as a long serving serviceman would be crucial in the transition without undue hardship from the regulated life of the serviceman to the competitive life of the general community in which the serviceman lacks experience as a member of the workforce 122 several other decisions indicate that the loss of entitlements is regarded as a significant loss for convicted veterans 123 as this suggests the pension due to a long serving serviceman is recognition of good character 124 and its loss a weighty collateral punishment for wrongdoing it is in light of the idea of veteran defendants as seethrough subjects that the judicial consideration given to the currently serving defendants probable discharge from the military should be understood the case law indicates that judges take the consequences of criminal conviction for serving military particularly seriously an illustration is provided by r v lancaster r v touhy in which the appeal court quashed the defendants sentences of imprisonment replacing them with good behavior orders on the basis that the fact that lancaster and touhy would suffer certain discharge from the army as a consequence of the imposition of a custodial sentence was not made perfectly clear to the sentencing judge and thus he did not give the consequences of discharge sufficient weight 125 in r v labanon the appeal court twice refers to dishonorable discharge from the navy and loss of financial entitlements as additional punishment 126 probable discharge seems to be regarded with such seriousness because unlike loss of a civilian job discharge is considered a negative moralevaluative judgment of the defendant himself further evidence of the seethrough quality of veteran defendants is apparent in the way military service quantifies the defendants professional standing in the community in part by reference to his rank by this i mean to suggest that the regimented and hierarchical nature of the military facilitates ready moral assessments of veteran defendants according to which some defendants are more deserving than others in r v caple it was accepted that the defendant who was convicted of seriously assaulting his partners 19 month old son was a senior sailor of very good character 127 according to the court the trial judge had given sufficient weight to good character alongside other relevant matters and it declined the crown appeal against sentence 128 similarly in reg v simpson the defendant was a warrant officer who had had a long and honourable career had been decorated and whose service was spoken of in the highest of terms 129 simpson was charged with the manslaughter of another officer for whom his wife had left him in that case simpsons past record and conduct his service to the community and the substantial financial loss of benefits which he must sustain was taken into account 130 the knowability of veteran defendants itself rests on a particular type and quantum of information available to the court for adjudication and evaluation when veterans came to the attention of the courts and made claims about their war and military service they were aided in part by the comprehensive recordkeeping of the armed forces and the repatriation department which later became the department of veterans affairs 131 for my purposes here what is significant is that as a practical matter such records provided the evidentiary basis on which the knowability of the exsoldier depends through the records available to the courts veteran defendants become more known and more knowable at law these records seem to have been particularly important for mental soldiers for instance in r v kennedy the defense tended a dva assessment dating from the time of the offenses which revealed the terribly pathetic lifestyle that kennedy had at that time 132 stephen garton argues that repatriation department files effectively captured personal problems of returned servicemen as war problems and the knowledge generated about these individuals and families seemed to be proof that there was something especially troubled about these men and their family lives 133 in relation to veteran defendants the criminal justice lens achieves the same thingthe effect of a veterans status as a mental soldier is to scope subsequent offenses through a war trauma lens in this sense veteran defendants are made subjects via a range of indirect informal measures of governance and the various expert social knowledges that came to the fore in western liberal political systems in the twentieth century 134 128 id at 117 129 see reg v simpson 76 wn 589 592 130 see id at 594 the sentence was increased from 3 years to 5 years by the appeal court 131 these sources have been mined by historians for a discussion of the value of these sources see larsson shattered anzacs supra note 29 at 2325 132 r v kennedy 2011 nswdc 223 15 this evidence assisted the defendant in that it allowed the court to conclude that specific deterrence should not play a significant part in sentence because the offenses occurred some time earlier had not been repeated and were the product of the situation which existed at the time id 24 133 garton supra note 28 at 199 134 v conclusion this article has offered a study of the criminal responsibility of returned service personnel charged with serious offenses after military or war service aiming to build on existing sociohistorical work on criminal responsibility my study presented one way of examining the social dimension of criminal responsibility practices as i discussed in this article premised on veterans as a distinct social category exsoldiers are accorded special status in criminal adjudication and sentencing practicesas veteran defendants my analysis of the special status of veteran defendantscentering on the veteran as a complex figure simultaneously agentic and victimlike courageous and vulnerable both more and less than other defendantsis not merely an acknowledgment that as part of a wider set of penal institutions and practices adjudication and evaluation are cultural practices influenced by legal traditions and norms as well as the relevant law 135 rather i have suggested that the social status of veterans is the basis on which members of this cohort are given special treatment in lawas übercitizens who generate responsibility in others involved in the criminal process and individuals with diminished capacity for crime each of these two substantive dimensions of the specialness of veteran defendants is underpinned by a formal quality of veteran defendantsas seethrough subjects both more known and more knowable than other defendants i suggested that there was a historical interplay between the two substantive dimensions of the specialness of veteran defendants with the latter becoming more prominent over time by way of conclusion i briefly highlight some of the implications of my approach by reference to the existing scholarly literature on criminal responsibility veterans have already received some attention in criminal responsibility scholarship in the legalphilosophical scholarly traditionbroadly the scholarship inspired by normative philosophical thinking 136 veterans are one example of what have been labelled difficult responsibility cases these cases present a challenge because the individuals involved do not seem to have the necessary human agency to be appropriately held to account for their actions through criminal law but are not amenable to categorization within traditional categories of nonresponsibility such as insanity in relation to these difficult responsibility cases the approach now prominent in the legalphilosophical literature utilizes prosecutorial standing to resolve such cases 137 several authors have questioned the states standing to blame certain individuals including military veterans and poor individuals 138 challenging the standing of the state to pursue a criminal charge 135 is a procedural solution because it invokes the scope of legal authority 139 and so the issue of the responsibility of certain individuals is pushed to the side my own study offered an alternative perspective on criminal responsibility in one category of these difficult types of cases it showed that the criminal responsibility of veteran defendants is negotiated in complex waysacross the distinctions between responsibility and liability conviction and sentencing character and capacity defenses and mitigation and punishment and treatment that as mentioned above generally mark criminal responsibility scholarship my study revealed that the relevance of veteran status to criminal law adjudication and evaluation did not reduce to any one of these grooves marking criminal responsibility scholarship indeed it is clear that veteran status is significant in multiple respects and at multiple points in time in criminal law practices 140 as a result focusing exclusively on the criminal trial the moment of adjudicationthe standard focus of criminal responsibility scholarswould have occluded other significant dimensions of the complex negotiation of responsibility in criminal law in particular my study revealed that in relation to the responsibility of veteran defendants the practice of sentencing was especially significant while sentencing is not typically a focus of criminal responsibility scholarship it seems clear that it may be understood as a negotiation of responsibility in some loose but important sense and thus that it would be usefully incorporated into responsibility scholarship in a scholarly context in which the dominant theories of sentencing grand notions of retributivism or just deserts seem to operate in a way that is disconnected from sentencing practices the individualization of sentencingmitigation and aggravationis not well theorized 141 the personal or individual aspects of the practice of sentencing have resisted reduction to desert theory with its overarching limitation of proportionality and have been considered in a theoretical vacuum 142 in particular there is a residue of mitigating factors such as character which does not fit neatly within dominant sentencing theory 143 war service seems to fall into its own miscellaneous mitigation category 144 my own study revealed that veteran status 139 john gardner relations of responsibility in crime punishment and responsibility the jurisprudence of antony duff 87 96 140 it is possible that veteran status impacts on the decision to prosecute and on jury decisionmaking but my sourcesreported and unreported judgmentsdid not enable me to test these possibilities 141 see andrew ashworth sentencing and criminal justice 156 142 see allan manson the search for principles of mitigation integrating cultural demands in mitigation and aggravation at sentencing 40 45 143 id 144 nigel walker suggests that in terms of mitigation war service can be chalked up as moral credit according to walker the idea that the defendant should receive moral credit for conduct that is unconnected to the offense is based on two assumptions that is taken into account at sentencing in multiple waysboth for and against the defendantand indeed that sentencing practices revealed a rather nuanced accounting of responsibility for crime this nuanced accounting for responsibility for crime exposed the ways in which actors other than the defendant are implicated in responsibility within the criminal process as discussed in relation to veteran defendants as übercitizens ascribing greater agency to veteran defendants generated responsibility in others involved in the adjudication and evaluation process i suggested that judges assumed responsibility for weighing up the sacrifices involved in war or military service to the state on the one hand and the seriousness of the offense on the other by contrast and as discussed in relation to veteran defendants as legal persons with diminished capacity to the extent that individuals were to blame for their war or military trauma with mental illness characterized as a personal failing rather than a consequence of war or military service to the state societys responsibility for them is reduced this complex economy of individual and social responsibility became apparent in adopting a social rather than a traditional or typical legal unit of analysis appreciating this complex economy of responsibility demands that sociohistorical or critical scholars of criminal responsibility think differently about individual defendants and take into account the broader institutional social and political context in which they are located in recent years the special status of returned service men charged with committing crimes has generated calls to establish specialist veterans courts along the lines of such courts in the us 145 the calls for veterans courts in australia represent the epitome of the idea of veteran defendants as a distinct and privileged group while to date such courts have not been established generalized appreciation that soldiers deserve gratitude and sympathy on the one hand and that war is criminogenic and exsoldiers have special needs 146 on the other continues to impact on criminal responsibility practices offenders are being sentenced not for the offense but for their moral worth and that moral worth can be calculated by a sort of moral bookkeeping in which spectacular actions count for more than negative decency see walker supra note 22 420 walkers palpable scepticism about these remarkable cases seems to arise from the fact that they involve a reduction in the proportionate sentence on grounds other than harm and culpability vi appendix index of cases

criminal responsibility now forms the subject of a rich vein of sociohistorical scholarly work but finding concrete ways to grasp the social dimension of criminal responsibility has proved challenging this article presents one way of examining the social dimension of responsibility practices in criminal law taking a social rather than a traditional or typical legal unit of analysis it presents a study of returned service personnel charged with serious offenses after returning home to australia i argue that premised on veterans as a distinct social category exsoldiers are accorded special status in criminal adjudication and sentencing practicesas veteran defendants the special status of veteran defendants has two substantive dimensions veteran defendants as übercitizens civic models or exemplars to whom gratitude is owed and who generate responsibility in others involved in the adjudication and evaluation process on the one hand and legal persons with diminished capacity who have impaired or reduced responsibility for crime on the other hand these two substantive dimensions of the specialness of veteran defendants are underpinned by a formal quality of veteran defendantsthat they are seethrough subjects both more known and more knowable than other defendants in the australian context there is a historical interplay between the two substantive dimensions of the specialness of veteran defendants with the latter becoming more prominent over time

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introduction 1research background as a relatively vulnerable group in society the attention of people with disabilities is an important symbol of social civilization and progress employment is one of the key ways to help disabled people achieve social integration therefore in the context of the new era studying how to promote the employment of people with disabilities improve their employment situation and promote their social integration by helping them achieve full employment has become an important research topic heilongjiang province located in northeast china has unique geographical conditions its vast plain distribution and close proximity to the national border add unique features to the region at the same time the harsh winter climate is also a major feature of this area and this climate characteristic may have an impact on employment in terms of economy as a developing region the industrial structure of heilongjiang province appears relatively unique agriculture has achieved significant development in this area resulting in a relatively large rural population all of these regional characteristics may have an impact on the employment of people with disabilities according to the second national sampling survey of disabled population in 2006 there are approximately 8296 million disabled people in china according to the sixth national census data the disabled population in china currently exceeds 85 million the total population of disabled people in heilongjiang province is 2189 million accounting for 687 of the total population which is higher than the national average of 634 highlighting the difficulty of employment services for disabled people in heilongjiang province in the context of comprehensively building a moderately prosperous society actively providing employment services for disabled people is crucial for the development of human society research purpose and significance this study aims to reveal the difficulties faced by disabled people in employment in heilongjiang province in order to explore their low employment rate low employment level and stability limited income level and limited employment opportunities and provide empirical support for improving the employment situation of disabled people this study will contribute to a deeper understanding of the practical difficulties faced by disabled individuals in employment in heilongjiang province provide targeted recommendations for policy makers promote the improvement of the employment environment for disabled individuals and achieve the goals of social inclusion and sustainable development at the same time revealing the problem also helps to attract broader social attention reduce prejudice against people with disabilities and create a more equal and inclusive social atmosphere advance research scholars such as yang weiguo qian pengjiang and xu lin have conducted thorough research on the employment status of disabled people and pointed out that there are still many problems and bottlenecks in the employment of disabled people at present firstly the employment rate of people with disabilities is generally low and there is a significant gap compared to the overall employment rate according to the results of the second national sampling survey on disabled people in 2006 the proportion of disabled people who are unemployed in urban areas exceeds 60 secondly the level of employment positions for people with disabilities is relatively low and the structure is unreasonable zhao yanpings survey found that over 90 of people with disabilities engage in simple physical labor luo qiuyue found through data analysis that the average salary for disabled people working in welfare enterprises is less than 60 of the social average thirdly the employment stability of people with disabilities is poor qing shisong et al found that when companies lay off employees the first person to lose their job is often the disabled 1 in terms of factors affecting the employment of disabled people liao juans study found that the employment rate of male disabled people is higher than that of female disabled people and that the employment rate of rural disabled people is higher than that of urban disabled people the influence of age shows an inverted ushaped feature and the employment rate of married people is significantly higher the improvement of education level and the acceptance of vocational skills training have a significant effect on improving the employment rate of disabled people with mental and intellectual disabilities facing the greatest employment barriers the inadequate employment support policies for disabled people are also another factor affecting their employment xu lin believes that employment support for people with disabilities should not only develop protective policies but also be synchronized with supportive policies zhang yongan pointed out that there are shortcomings in certain aspects of the current employment policy for people with disabilities and there is great room for improvement therefore it is urgent to improve chinas employment policies for people with disabilities in recent years china has formulated many inclusive or preferential policies to promote the employment of people with disabilities from the central to local levels however the issue of employment for people with disabilities remains severe and this phenomenon deserves profound reflection 2 research methods this article mainly uses the research methods of literature research and questionnaire survey to analyze the current situation of employment of disabled people in heilongjiang province and summarizes the problems in the employment of disabled people in heilongjiang province analysis of the current situation of disabled persons and their employment in heilongjiang province current situation of disabled persons in heilongjiang province according to the national disabled population data released by the china disabled persons federation as of december 31 2020 1103 million people in heilongjiang province have obtained disability certificates accounting for 5039 of the total disabled population a total of 37807 million people in china have applied for disability certificates accounting for 4556 of the total disabled population it can be seen that the disability certification rate in heilongjiang province is higher than the national average reflecting the high awareness of disability certification in the region 3 211 from the perspective of age structure among the disabled who have obtained a disability certificate the proportion of the main employment age group aged 1559 is significantly higher than the national average this indicates that heilongjiang province needs to focus on the disabled population of employment age and actively solve their employment problems from a gender perspective among the disabled people who have obtained disability certificates in heilongjiang province the total number of female disabled people exceeds 420000 which means that in terms of employment skills training it is necessary to consider the employment needs of female disabled people at the same time the number of male disabled people is 157 times that of female disabled people the large number of male disabled people can cause significant pressure on family conditions and affect the formation of families men may bear more of the burden of family life and need employment to alleviate the economic pressure on families 4 from the perspective of disability level among the disabled people who have obtained disability certificates in heilongjiang province there are 125695 people in the first level of disability and 311957 people in the second level accounting for 3966 people in the first level of disability have almost lost their employment ability due to physical reasons but people in other disability levels have a certain degree of employment ability the proportion of severe disabilities is relatively small and most people with disabilities still have employability and can better integrate into society and create value therefore it is necessary to strengthen support for disabled people of other levels and increase their employability 5 from the perspective of disability types nearly 60 of disabled people still have physical disabilities with visual disabilities ranking second and hearing and speech disabilities accounting for 945 ranking third these three types of disabilities have relatively good selfcare and employment abilities compared to other types and are also key groups for employment from the perspective of education level among the disabled in heilongjiang province 8451 have received nineyear compulsory education and the illiteracy rate is relatively low as of 2022 there are a total of 5 secondary vocational schools for the disabled with 359 students and 73 graduates suihua college in heilongjiang province began recruiting hearing impaired students nationwide in 2011 offering preferential policies such as free tuition and separate enrollment promoting the development of higher education for people with disabilities and improving their educational level the improvement of education level for disabled people has a positive impact on employment it can not only create more employment opportunities and improve income levels for people with disabilities but also promote their selfdevelopment enhance social identity and promote social inclusion and equality 6 current situation of employment for disabled persons in heilongjiang province currently there are three main ways of employment for people with disabilities in china centralized employment decentralized proportional employment and independent employment centralized employment mainly arranges the collective employment of disabled people in welfare enterprises which plays an indispensable role in solving the employment of disabled people decentralized proportional employment where enterprises hire disabled employees to participate in enterprise labor at a certain proportion also enhances the professional competitiveness of disabled people to a certain extent enriches their employment forms stimulates their work potential reduces their employment pressure and encourages them to integrate into society in february 2007 the state council issued the regulations on the employment of persons with disabilities which stipulates in article 8 that the proportion of employers arranging employment for persons with disabilities shall not be less than 15 of the total number of employees in their own units and the number of public welfare positions for persons with disabilities shall not be less than 10 of the total development amount of the human resources and social security department selfemployment with flexible and diverse forms is mostly for individual employment it operates traditional industry projects with low technical requirements and does not require a large amount of funds the entry threshold for disabled people is also relatively low 7 from the perspective of employment rate among the disabled people who have obtained disability certificates in heilongjiang province the employment rate of working age is 3179 which is lower than the overall employment rate of 495 for disabled people nationwide the employment problems faced by disabled people are relatively severe from the perspective of employment structure heilongjiang province is located in the northeast region of china with vast farmland and abundant agricultural resources the region is suitable for agricultural development including planting animal husbandry and fishing people with disabilities are relatively easy to find employment opportunities in the agricultural field and the working environment in agriculture is relatively open and flexible with less physical limitations therefore among the disabled people who have achieved employment in heilongjiang province the type of employment they engage in accounts for the largest proportion which is agricultural planting breeding and processing accounting for nearly half of the total secondly there are flexible employment and individual employment however less than 9 of people with disabilities are engaged in proportional employment and concentrated employment which have relatively good employment stability the overall employment situation lacks stability in summary in response to the current employment situation of disabled people in heilongjiang province it is necessary to increase support and training for disabled groups of employment age while paying attention to the employment needs of female disabled people and enhancing their ability to participate in professional competition in addition for other levels of disabled people support should be strengthened to enhance their employability and better integrate into society at the same time encourage diversified employment methods and promote the development of more stable proportional employment and concentrated employment positions through these efforts the employment status of disabled people in heilongjiang province can be improved and social inclusion and equality can be promoted problems in the employment of disabled persons in heilongjiang province in order to understand the problems in the employment of disabled people in heilongjiang province a survey was conducted on the current employment situation of disabled people during the survey and research process a survey questionnaire was designed to address the three main factors that affect the employment of disabled individuals government society and individuals with disabilities the survey was conducted from the perspectives of service system disability level education level and salary income a random sampling method was used to select 240 disabled individuals from the provincial disability certification system for the survey a total of 240 survey questionnaires were distributed and 205 valid questionnaires were collected according to statistics among the 205 disabled people who participated in the survey questionnaire there were 110 males and 95 females and 77 were employed with an employment rate of 376 low employment rate the employment rate of certified disabled people in the employment age group in heilongjiang province is 3179 far lower than the national average employment rate of 495 compared with advanced regions such as guangzhou jiangsu province and shandong province there is still a certain gap many disabled people lack the awareness of independent employment due to their heavy reliance on thought which also affects the overall employment rate of disabled people in heilongjiang province low level of education the education level generally accepted by disabled people is not high among the 205 disabled people surveyed 77 have no education 63 have primary education 45 have junior high school education 12 have high school education and only 8 have received vocational education or above only 10 of those who receive high vocational education or above the education level of disabled people is generally low in terms of vocational skills training only 36 people have received training and 62 people have not received training the retraining of employment for disabled people is not widespread enough due to factors such as low education level and low cultural level people with disabilities in heilongjiang province often have to work in jobs with a single structure poor stability and high substitutability which also increases the difficulty of employment for people with disabilities in heilongjiang province for example although blind people can engage in blind massage due to the limited labor demand in this industry it is almost saturated therefore even if many blind people have the willingness to work in this area it is still difficult to achieve employment 8 figure 2 education level of persons with disabilities insufficient employment channels and poor stability due to their own physical barriers and different occupational skills the individualized employment needs of disabled individuals are relatively scattered and have significant differences requiring a wider range of employment channels from the perspective of the main channels for employment among the 98 disabled people who have already been employed 30 are engaged in agricultural planting 28 are employed flexibly 24 are self employed and 16 are provided with public welfare positions through the government or relevant institutions the employment channels for disabled people in heilongjiang province are mainly based on agricultural farming flexible employment and independent entrepreneurship accounting for 84 of the employment channels new channels such as auxiliary employment and public welfare employment have not been well utilized far from meeting the diverse and personalized employment needs of people with disabilities and the employment channels for people with disabilities are not wide enough the problem of poor employment stability and lack of longterm employment security will result in a high likelihood of disabled people who have already achieved employment in heilongjiang province becoming unemployed again during the employment process further reducing the employment rate of disabled people in heilongjiang province most people with disabilities who engage in relatively unstable employment types need to pay their own pension insurance in addition the low income causes them to give up their pension insurance payment without pension insurance protection many people with disabilities will have a more significant burden on their personal and family life as they age figure 3 main channels for disabled people to achieve employment low quality of employment and low income due to the limitations of the physical educational level and personal qualities of people with disabilities they often engage in jobs that require low technical skills are easy to operate have simple procedures and have strong substitutability overall they are at the lower level of employment and their work is unstable among the employed disabled people who participated in the survey 68 were engaged in agriculture and frontline physical work among the 98 employed disabled people who participated in the survey 41 were satisfied with their work and 57 were dissatisfied according to survey data analysis 54 of people with disabilities have incomes below 1500 yuan 36 have incomes between 1500 and 2000 yuan and only 10 have incomes above 2000 yuan the labor income of most employed disabled people is below the average minimum wage standard of 1640 yuan in heilongjiang province some are even lower than the annual subsistence allowance income of disabled people and cannot become their primary source of income such low income coupled with increasing prices medical and other basic living expenses makes it difficult for people with disabilities to ensure their livelihoods and solve the basic problem of food and clothing among the disabled people who have achieved employment there are still a large proportion who cannot rely on their own income to achieve selfsufficiency which brings great economic pressure and burden to the families of disabled people in heilongjiang province uneven employment development the imbalance in employment of disabled people in heilongjiang province is mainly reflected in aspects such as gender household registration disability category disability level and employment skills from the perspective of disabled persons household registration among the 98 employed disabled persons urban household registration is 62 and rural household registration is 36 the number of urban disabled persons employed is greater than that of rural disabled persons from the perspective of disability types 46 people have visual disabilities and 20 are employed 30 people with speech disabilities and 21 people employed 34 people with hearing disabilities and 22 people employed 21 people with intellectual disabilities and 6 people employed 17 people with mental disabilities and 0 employed 45 people with physical disabilities and 29 people employed 12 people with multiple disabilities and 0 employed the number of people with mental and severe disabilities employed is much lower than that of other types of disabilities 9 the different types of disabilities objectively limit the scope of employment that disabled people in heilongjiang province can engage in for example most disabled individuals with visual impairments are unable to work in jobs that require high levels of vision such as traffic police enterprise controllers art teachers etc while those with language and hearing impairments are mostly unable to work in jobs that require high levels of communication and expression skills such as telephone operators tour guides secretaries etc most people with intellectual disabilities are unable to engage in scientific research such as development and application research most people with physical disabilities are unable to engage in work that requires significant physical strength such as transportation and construction at the same time the level of disability among individuals with disabilities also has a significant impact on the types of employment options available such as the inability of individuals with secondary disabilities to engage in physical work this will also make it difficult for many disabled people to achieve employment in certain fields they want to work in further increasing the limitations of employment choices for disabled people the limitations of employment choices for people with disabilities can lead many to have serious doubts about whether they can ultimately achieve employment affect their confidence in employment reduce their willingness to work and thus have a negative impact on promoting the employment of people with disabilities in heilongjiang province 10 conclusion in recent years although the employment situation of disabled people in china has been improving year by year through the continuous efforts of the country and the government the current employment situation is still not ideal especially in heilongjiang province there are still problems with low employment rates low levels of employment lowincome levels and imbalanced employment for disabled people the issue of employment for disabled people is a systematic work that requires the joint efforts of the government society and the disabled themselves it is necessary to propose corresponding countermeasures based on the actual employment situation of disabled people in heilongjiang province while drawing on the experience of advanced regions to promote the continuous development of the cause of disabled people

employment of disabled people is an important way to ensure their basic livelihood social participation and realize their life value however due to the varying degrees of physical or psychological deficiencies that disabled individuals have compared to healthy individuals their employment rate and income level are often lower than those of healthy individuals in addition there is a cognitive bias towards people with disabilities in society which leads to social exclusion in various aspects such as politics economy and culture exacerbating the employment difficulties of people with disabilities and hindering their pace of social integration this article takes heilongjiang province as an example focusing on the disabled group with labor ability and studying their employment issues at present there are still a large number of disabled people in heilongjiang province with poor quality of life making it difficult to integrate into mainstream society which poses serious obstacles to achieving a comprehensive welloff society including disabled people this article first explains the overview of disabled people and their employment in heilongjiang province secondly relevant employment data for disabled people were obtained through a questionnaire survey finally by combining the data from the overview of disabled people in heilongjiang province with the data obtained from the questionnaire survey it was found that there are problems with the employment of disabled people in heilongjiang province mainly including low employment rate low level and stability after employment low income level and significant employment limitations

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background worldwide family carers are the critical sources of support for persons living with dementia 1 family carers of persons living with dementia are relatives friends or neighbors who usually provide unpaid care and continue to provide care even after their relative moves into longterm care 23 carers may experience relief when their family member is admitted to ltc but several studies have shown that they often continue to experience burden and emotional distress 4 5 6 7 these feelings may be due to their negative perceptions of dementiacare and feeling that they have abandoned their family member 89 family carers of persons living with dementia residing in ltc are atrisk for poor mental health outcomes as their mental health often worsens after their family member moves into ltc and need ongoing support 1011 a narrative review of 12 qualitative studies describing the experiences of carers of persons living with dementia residing in ltc clearly identified the worry and anxiety grief and loss guilt and despair experienced by these carers 12 hennings and froggatt 8 also described the significant changes that carers experienced such as the evolving relationships with their family member their own need for companionship and the need to face endoflife issues more recent studies suggest that carers of persons residing in ltc also experience significant changes such as a transfer in responsibilities from being the primary caregiver to a visitor new relationships with ltc staff members and feelings of grief and loss of hope 111314 carers need to adjust to a new way of living both for themselves and for the person with dementia 1015 however the literature remains unclear as to the best ways to support family carers as two recent systematic reviews suggested there is little evidence available and there is a significant need to improve evidencebased interventions to support carers 1617 purpose the purpose of this study was to address the following research questions 1 how do carers deal with significant changes when their family member with dementia resides in ltc and 2 what are the carers perceptions of their support needs when dealing with these changes methods this qualitative study was part of a larger study whose purpose was to adapt and evaluate an online toolkit to support family carers of persons living with dementia in ltc 18 in the first phase of the larger study focus groups were conducted with carers of persons living with dementia in ltc focus groups were utilized as they have been found to elicit more personal sensitive data than individual interviews 19 the focus groups addressed the following questions what is the experience of significant changes for carers of persons living with dementia in ltc facilities what would help with these changes what are carers experience of loneliness and how should mt4cin care be adapted to best suit carers needs this article reports findings related to the significant changes that carers experiences through an analysis of data gathered from the first three questions a discussion of factors associated with carers feelings of loneliness and how mt4cin care should be adapted to address loneliness is reported elsewhere the qualitative focus group data were analyzed using an applied qualitative thematic approach 20 this includes aspects of grounded theory and phenomenology to address research questions in applied research settings using this approach allowed the research team to identify and describe processes of how carers dealt with the significant changes they experience without developing a substantive theory that is often the outcome of grounded theory the multidisciplinary research team included nurses a geriatrician a statistician and a clinical psychologist who contributed to aspects of the study focus group interview data were collected from september 2019 to january 2020 ethics approvals for these interviews involving human participants were successfully obtained in all involved provinces the standards for reporting qualitative research guidelines 21 were incorporated into this report participants and setting there were multiple community and ltc settings for this study as it was conducted in four canadian provinces fortyfive participants were recruited using convenience sampling through different provincial alzheimer societies and ltc homes inclusion criterion were 1 18 years of age 2 english speaking 3 selfidentified as a family friend of older persons in any stage of dementia currently residing in ltc and 4 a valid email address and access to a working computer and internet potential participants who met the inclusion criteria were asked by staff of the recruiting organizations if they were interested in participating in a focus group with their permission the email addresses of potential participants were sent to trained research assistants the research assistants then contacted potential participants explained the study and answered any questions data collection in advance of the focus group sessions a copy of the demographic form focus group questions and consent forms were emailed to the participants at the start of the focus group session research assistants obtained written informed consent and collected demographic information using a selfreport form carer participants were given information about the different stages of dementia and asked to determine their family member stage of dementia two facetoface focus group interviews were conducted in each of four provinces by two trained facilitators one facilitator led the session while the other took detailed notes three to eight carers participated in an approximately 90minute audiotaped focus groups focus groups were conducted in locations that were comfortable and easily accessible for the participants moderators used a semi structured interview guide and asked the following questions • could you please tell us about the biggest changes you have experienced as a caregiver after your family member andor friend was admitted to a longtermcare facility • what would help with these changes • can you tell us about a time when you felt left out or isolated after your family memberfriend was living in longterm care moderators adapted the questions based on the responses of the participants and also used prompts and follow up questions to gather more indepth information data analysis demographic information was entered into spssv24 22 and analyzed using descriptive statistics all interview data and field notes were transcribed and anonymized by an experienced transcriptionist and checked for accuracy by research assistants in each province focus group data were aggregated from all sites and analyzed together guest et al s 20 applied thematic analysis was conducted using the following steps 1 transcripts were read and reread as a whole with a focus of the analytic objective 2 common patterns in the data across groups were identified examining similarities and differences 3 data were grouped into processes using a constant comparative approach and 4 collective high level themes representing all the focus group data were identified then based on these high level themes an overarching theme was conceptualized the first four steps were completed by the first author then the research team reviewed the findings and data findings were revised until agreement within the research team was reached the participants own words were used as much as possible to describe the themes and an audit trail was kept to ensure trustworthiness of the data 20 findings building a new life participants dealt with the significant changes by building a new life some of the participants felt they had to build this new life alone as one participant said building a new lifealone you have to establish your new life another participant said that … this is a different life for now and temporary… suggesting this new life is one they realized would change as their family members condition progressed participants noted benefits to building this new life such as being able to reconnect with activities and others they had once enjoyed …and im finding that ive started new things i get back doing things that i enjoy things that ive had to put off quite a while they built a new life by a building new relationships and b finding space for themselves factors supporting building a new life were a understanding dementia b support from others c connecting with resources and d being included in care decisions 3 presents transcripts examples for the themes and subthemes building new relationships new relationships were created with their family memberfriend residing in ltc with ltc staff and with others outside of ltc these subthemes are described below family memberfriend the new relationships with their family member with dementia was attributed to the decline in their family members health i categorize most of the changes as having to do with building a new relationship with my family member living in ltc its not something that happened the day they moved into longterm care because this has been already quite a long journey in terms of seeing a decline at home and caring at home and then getting personal care at home and home care in so there has been stages all along the way participants described the changes with their family members as occurring over time one of the most distressing changes was related to the declining ability of their family member to communicate its a lack of communication sorry as my mom when she moved into the long term care facility the hill thats shes going downhill is steeper quicker and for a lack of her because she wasnt doing as much its her lack of communication i cant sit and have a conversation with my mom which makes feel lonely… however changes in relationships and the caregiving role were not always perceived as negative because i do find that one of the major changes in my wife going to longterm care is that now im not the bad guy im not the one making her have to take her medication they are so when i go in there shes actually happy to see me again staff building relationships with staff was also important for the participants knowing the staff the psws personal support workers theyre your link as one participant explained you have to become part of the team but you cant become in charge of the team you have to just work with the team becoming a member of the team enabled carers to find space for themselves in their new life outside of ltc reestablishing relationships with previous individuals or establishing new relationships with people outside of ltc was important as well and so trying to navigate differently in terms of reestablishing some relationships you left behind or establishing new relationships or maybe getting reinvolved in some things that you withdrew from while you were a caregiver at home so i see it in one hand a relationship with your spouse and on the finding space for themselves to find space for themselves in their new life participants described negotiating the sharing of care of their family member with ltc staff and finding the right balance between their life with their family member in ltc and a life outside of ltc this quote suggests that it was not always easy for carers to find space for themselves but it was important im part of what made finding space for themselves difficult was the need to relinquish some of the care they had been providing to ltc staff sharing care relinquishing some of the care of their family member to ltc staff in order to share the care of their relativefriend was difficult for some participants for some it took time to realize they were not alone in providing care im not doing this by myself anymore in another focus group participants described how they no longer provided hands on care but provided emotional care for their family member instead for example one participant said yeah i think its a i think i mean im sort of a caregiver but not as handson so when i see isits a tradeoff so you know youve given up the daytoday physical now theres the emotional and the worry right so its different however in the same focus group a participant said that roles changed and the emotion and worry decreased over time i think thats true at the beginning when theyre admitted but it will be two years for my wife next month and you know i think i dont know how much were managing it now its just the staff know her very well sort of many participants were unable to engage in sharing of care because of their worry about the care being provided by the ltc staff participants expressed anger and frustration regarding the poor quality of care their family member received and ended up feeling they needed to be with their family member almost all of the time as one participant said i have no more time to do anything it is just like running around all the time total care this interfered with their ability to negotiate sharing of care with staff and subsequently find space for their new life the physical environment of the home at times also contributed to the carers feelings of guilt worry and anxiety regarding their family member for example one participant said when my mom moved in to this facility she was on the first floor and it was really dark and it was just it was the physical environment was depressing as a result she felt she needed to provide additional emotional support and care for her mother and visit more often then she would have if the environment was brighter sharing of care was also problematic if the food served in the facility was difficult to swallow or not appetizing for some participants this meant they needed to bring food from home or attend each meal the physical environment was also a factor that at times prevented participants from engaging in sharing of care finding balance similar to sharing care finding a balance between being with their family member in ltc and building a new life was difficult so with me if i come at least twice a day and i try to do three times a day but its really hard with you know like having a life like doing your shopping and you know shoveling your driveway and… this was particularly difficult when participants felt they were unable to relinquish some of the care to staff so i try to come three times a day but when i comeand the other thing is he doesnt respond right away theyll leave him and i come in at 1030 and hes sitting in front of his breakfast so its the added guilt of you know guilt was a feeling often described by participants when they were finding it difficult to balance their time with their family member and their life outside of ltc finding a balance between their life with their family member and their outside life also consisted of making decisions about their level of involvement in their family members care and when to intervene on their behalf … and you know even um decisions about how involved you get in the persons care like working out the relationship with the person that youre caring for but also with the caregivers staff that are there and trying to find the right balance of intervention and so on factors supporting building a new life what helped participants to build a new life was described in four themes a understanding dementia b support from others c connecting with resources and d being included in care decisions understanding dementia one participant described the importance of understanding dementia as the disease had become part of them as well i think its understanding the disease its not only with the patient the disease is also with the caregiver this quote emphasized the interrelationships between the carer and their family member this suggested that dementia is part of the carers life as well and understanding dementia would assist the carer to build a new life understanding dementia also helped participants prepare for the future … she physician prepares you extremely well for the future and once you adopt that you can move forward thats what i found if you try to fight it you are in chaos the whole time so i think that in my case and i dont know about others but the more knowledge that i had and the more people that were experts socalled in their particular fields whether it was ot physio social worker doctors who really understood dementia participants valued information about dementia from those they considered experts they also emphasized that this knowledge was critical for preparing for their future and the future of their family member unfortunately not all participants were able to access information from experts i dont think that really good information is out there either for people seeking it or for people that need to know support from others support from others in particular other family members and friends also helped calling on others for support i think is huge thats one of the things that i said you know just rallying the troops and just get everybody you know to come and visit care recipient come and visit for half an hour once a week or once a month or whatever you can afford right to take some of that pressure off taking pressure off the carer to be physically present in the ltc home would also provide space to build a new life connecting with resources the participants also described the importance of resources to support them as carers something to help … so i can discuss my concerns can help build my confidence in the facility and the staff as well as maybe a resource list of when things kind of fail you can reach out to these people to help you advocate for what they need this quote suggested that resources were needed in several areas so the participant could advocate for a family member others also described wanting resources to reach out to when they were having a difficult time and support groups that would be great id love to go to a support group but i had no idea there is such a thing but just a general list of things in your community that you can reach out to and talk to and… participants also wanted to be able to talk with others carers of persons residing in ltc … finding people who are in the same boat you are and finding out youre going down the same river and paddling the same way theres nothing like it the opportunity to talk with other carers who were also having a similar experience was helpful as the participants often felt other people did not understand what they were going through included in care decisions participants noted that being included in care decisions by the staff would also help with sharing of care and were not getting care conferences …i think thats a way of isolating me like keeping me out of the loop he has a lot of medical needs but i think i get the feeling that the doctor and the nurses hub bub about and they dont you know they dont include me in the circle this feeling of exclusion regarding decision making about their family member was described in all of the focus groups some suggested it made them feel isolated which got worse as their family members condition worsened i felt isolated by the home…i felt they kind of took ownership of him and i sort of felt like i was left out of the decisionmaking… and it seems to get worse the as his disease progresses participants suggested monthly meetings may help i think one of the things i like the most with regards to that type of thing is that they have the monthly meeting with family members to deal with any concerns the family members have with regards to the care that their family members who are whether its the facility itself… a structured way of communicating with carers and provision of opportunities to be involved in care decisionmaking would support carers discussion carers adjusted to the significant changes they experienced when their family member resided in ltc by building a new life it required them to seek help as well as connect with resources and others while remaining involved in their family members care building a new life was achieved by building new relationships and finding space for themselves through sharing care and finding balance in their lives building a new life as a process described by carers to deal with the significant changes they experienced is a unique finding in the literature although other studies have described carers of persons residing in ltc as having a new or different life 51024 these studies did not describe the processes carers used to build this new life as well they did not describe factors that support carers to build their new life the process of building a new life included building new relationships and finding space for themselves in building their new life participants described building new relationships with ltc staff building relationships with ltc staff was a common theme in several studies 101225 these studies described the challenges that carers face in building relationships with staff as staff perceived carers as visitors who are difficult and demanding 1025 our findings suggested carers realized they needed to be a member of the team to be a team member carers worked to get to know the staff as individuals this is similar to the findings of a qualitative study of seven carers that suggested developing communication through informal contact with staff enabled family and staff alike to build a personal connection 25 carers highly valued interactions and communication with staff when they felt there was a personal connection 13 our findings extend these previous findings and suggested that establishing personal connections was an important component of communicating with ltc staff but also with the goal of becoming a member of the care team carers also had to continuously develop new relationships with their family member or friend with dementia some studies described difficulties and distress experienced by carers as a result of the physical deterioration and cognitive decline of their family member living with dementia 2627 the literature also described changes in the carers role as their tasks changed 591528 however these studies did not describe the work of carers to continuously redefine and develop new relationships with their family member that were described by our participants an important aspect of developing new relationships was the need for participants to develop relationships with others outside of the ltc setting this seemed to help carers deal with feelings of loneliness which appears to be a common experience of carers of persons with dementia residing in ltc 1012 previous research has not described the need for carers to develop new relationships outside of ltc carers particularly those who have limited social networks and are unable to share care may find building new relationships outside of ltc difficult in our study developing new relationships outside of ltc was also an important step to building a new life however how best to support carers to develop new relationships requires further research the need for carers to find space for themselves has not been reported in previous studies however similar findings of sharing care and finding a balance have been reported for example relinquishing some aspects of care to ltc staff was described in several qualitative studies 91015 many carers found this difficult as they felt guilt and ongoing responsibility for their family members wellbeing 1228 our participants described difficulties related to relinquishing some of the care of their family member to ltc staff when they believed the quality of care was poor when this occurred balancing their two worlds the one in ltc and the other outside of ltc was very difficult the struggle of balancing two worlds when carers were concerned about the care their family member was receiving was also reported in a mixed methods study examining interpersonal and contextual factors that influence carerstaff relationships 13 although focused on carerstaff relationships zamora et al reported the quality and appropriateness of care was an important factor influencing carers experiences concerns were expressed regarding personal care provided medication management safety falls wandering abuse and neglect resulting in carer distress and anxiety physical environment also impacted the carers experiences as lack of privacy and room for activities worried the carers in our study it was the darkness of the environment and quality of the food that was most concerning thus the quality of care and physical environment would possibly make it difficult for carers to feel they could share care and as a result be unable to find balance in their world with their family member in ltc and outside of ltc however more research is needed to determine if this is the case in another study finding a balance between their world within ltc and their world outside of ltc was key to carers finding hope in their lives 29 suggesting this balance important for carers mental health however other studies did not describe how finding a balance and sharing of care was important for carers to find space for themselves as was described by our participants the participants described four aspects that helped them to build a new life a understanding dementia b support from others c connecting with resources and d being included in care decisions understanding dementia support from others and connecting with information have also been described in previous studies for example the need for information and support is echoed in a study of 17 bereaved carers of persons with dementia who had resided in ltc 30 similar to our study thompson et al 30 described informational needs of carers regarding dementia its prognosis its clinical course and end of life issues however in our study the participants requested this information from those they considered experts this is similar to findings from a metasynthesis study of the experiences of carers of persons with advanced cancer 31 in this study the authors synthesized the findings of 72 qualitative studies of carers experiences they found timely information from trusted experts and networks supported carers during their experience similar to our findings and those of thompson et al supportive networks included family friends and health care providers connecting with resources involved carers having someone to express their concerns to as well as resources to help them build confidence as an advocate for their family member like information they wanted these resources to be available in a timely manner these are similar findings reported in a recent systematic review of carers needs across settings 17 in their review mueller et al 17 found carers wanted to improve their confidence in their new caregiving roles such as communication with staff they also wanted access to support groups and mental health services in a qualitative study of 9 spousal carers in australia suggested that peer support groups where carers can share their concerns as well as navigator support to navigate the health and social care systems maybe useful resources for carers 32 in previous literature being included in care decisions has been seen as a benefit to residents and to carers as it increased their satisfaction with care 33 for example shareddecision making involving residents families and ltc staff has benefited residents such as improving residents care plans 3334 the findings from our study suggests that being involved in care decisions has the additional benefit to the carers of decreased feelings of loneliness shared decisionmaking also helps carers with respect to relinquishing of care and moving to shared care which facilitates the process of carers building a new life however more research is needed to verify if this is the case limitations there were several limitations to this study as most of the participants were white well educated female married and had access to email more research is needed with diverse groups of carers to determine if findings are similar the methodology also involved focus group interviews which did not allow for indepth individual understanding of participants experiences focus groups are useful when discussing difficult topics such as the carers experience as some participants feel more comfortable in a group setting however even the experienced moderators could not ensure all participants were given the opportunity to fully describe their experience more research is needed to gain an indepth understanding of the carers experiences using individual interviews conclusion the findings of this study describe how family carers deal with lifealtering changes by building a new life and how carers could benefit from support in this process factors that supported them in building a new life also provide areas for future interventions these included a understanding dementia b support from others c connecting with resources and d being included in care decisions in some ltc settings improvements in care may be needed before meaningful relationships and sharing of care between staff and carers can be established the findings also underscore how the quality of care and the environment in which the person with dementia resides are key factors that should be considered in future research with carers abbreviations fg focus group ltc long term care authors contributions wd is the lead author conducted the analysis and along with ho is the study lead responsible for all materials from start to finish pbcngtspsgjh cm vd js contributed to the interpretation of data and the writing of the manuscript js and mp contributed to the data collection and ss contributed to the literature review all authors read and approved the final manuscript competing interests the authors declared no potential competing or conflict of interest with respect to the research authorship andor publication of the 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background family carers of persons living with dementia who are residing in long term care ltc often experience significant changes in their roles and relationships which affects mental and physical health research has focused on describing the carers experience but not on how they deal with these changes or their perceptions of support needs the purpose of this study was to explore how family carers of persons living with dementia residing in ltc deal with significant changes and to understand how best to support these carers methods eight facetoface audiorecorded focus group interviews were conducted with 45 participants from september 2019 to january 2020 as part of a larger study aimed at guiding the adaptation of an online toolkit to support family carers of persons living with dementia residing in ltc applied thematic analysis was used to analyze the focus group data findingsresults carers dealt with the significant changes they experienced through the process of building a new life consisting of two subprocesses a building new relationships with their family member ltc staff and others outside of ltc and b finding space for themselves sharing of care and finding balance understanding dementia support from others staff family and friends connecting with resources and being included in care decisions helped carers build a new lifethe process of building a new life describes the ways that family carers deal with the lifealtering changes they experienced when a family member is admitted to ltc carers may be supported in building their new life by providing them with information about dementia and how to relate to staff and their family member living with dementia the quality of care being provided and the ltc environment may also play an important role in how carers deal with the significant changes they experience

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i introduction sensors and platforms for communication and entertainment have become a natural part of our everyday lives for example in the xbox kinect platform osns games and media sharing are integrated thus allowing sensors to recognize your body and mirror your movements and make you the controller sensors have been increasingly attached to individuals via their mobile phones and are then able to deliver information about various aspects of the real world to applications and users alike sensors provide a wide range of opportunities for measuring collecting processing and distributing information in a multitude of application domains the term sensing is used in a broad sense in the paper which means that the discussions are not limited to what can be achieved with typical physical sensors data the new sensor paradigm leverages humans as part of the sensing environment therefore the term opportunistic people centered sensing has been introduced to describe this new paradigm in which mobile units carried by individuals in their daily activities sense information directly or indirectly related to human activity as well as other aspects 1 in opportunistic networks the nodes come into contact with each other opportunistically and then connect wirelessly for example if an individual carries a mobile phone into an airport lounge the phone might connect automatically to the wireless hotspot provided by the lounge and then the starting page of the browser in the phone might display relevant local information about restaurants newsstands and lounges these types of networks also mimic the way humans come into contact with each other and are therefore tightly coupled with human relationships and real world social networks the widespread use of mobile phones like iphone and blackberry with integrated communication capabilities and sensors such as wifi bluetooth radiofrequency ids cameras microphones accelerometers and global positioning systems along with other embedded sensors in vehicles and surveillance systems creates a large number of contact opportunities that are key to opportunistic sensing however the full potential utilization of opportunistic sensing requires new networking security and computing paradigms many works in the literature 1 2 3 have discussed the security challenges for sensing networks in which they focus on privacy users want to control who may access information about themselves also since the collected data may originate from devices that are out of their control the integrity of the data comes into question as well as the availability of the infrastructure one the one hand it has become increasingly evident that the integration of sensors applications and osns creates new and interesting opportunities on the other hand the coexistence of several components also creates challenges that need to be addressed we believe that given the mentioned security challenges and the recent availability of both digitized social informatics and sensor content we now have the option to examine multiple sources of information simultaneously and then create innovative ways to create a trustworthy communication environment trust is based on reputation between individuals which is a capital asset that people may invest great amount of resources in building it and that is acquired slowly but can be destroyed very quickly 4 6 therefore we consider trust between users as dynamic including social context into the information generation and delivery process provides greater assurance for receiving trustworthy content 7 9 in this position paper we use the term social informatics to refer to any digitized profile data interaction data or content available from the osn therefore social informatics includes the social relationships and their dynamics social relationship might change while some of them might be temporary virtually private or missionoriented social informatics also includes the communication activities or interactions over a graph of social relationships and the policy such as privacy or anonymity guarding those activities in practice the availability of the social informatics is usually constrained by the programming interface ii examples of opportunistic sensing there is currently a big push in the direction towards opportunistic sensing several examples exist from the networking domain for example the haggle project and the metrosense project 10 develop new applications classification techniques privacyenhancing approaches and sensing paradigms for mobile devices enabling a global mobile sensor network capable of societalscale sensing even though the development of new and smaller sensors is emerging we believe that the algorithm is currently more interesting than the sensors researchers typically put more emphasis on context engines and predictive analysis that is the focus is on software rather than hardware a recent project at mit aims at having a city that performs as a real time control system in which devices collect the movement patterns of people and transportation systems and their spatial and social usage of streets and neighborhoods a more commercial application performing similar realtime location data analysis called citysense has been developed for iphone and blackberry mobile phones to analyze and aggregate human behavior and to visualize a live map of city activity these kinds of sensorenabled applications are still far from being widely deployed and opportunistic computing and sensing initiatives are still in their infancy 11 however it is not difficult to imagine how this development could become the future of social networking in many ways firstly the mobile phones will be the primary way for the younger generation to explore social networks and organize social activities and relationships secondly with the next generation of web applications we will move beyond the era in which information has been used primarily for visualization instead the information provided might influence decisions and actions to a greater extent another interesting project is the cenceme 12 system that leverage the growing integration of sensors into offtheshelf consumer devices this personal sensing system enables members of social networks to share their sensing presence with their online friends allowing for a new level of implicit communication opportunistic sensing can also be used in many different application areas such as tactical networks intelligent transportation systems and pervasive healthcare communication is also of crucial importance in order to handle accidents and critical situations the osn environment can be combined with sensor technology to collect user data in order to perform reliable crisis risk estimation and to distribute warning messages news and information to the general public in the event of emergencies extraordinary events and periods of high alert in order to enhance crisis management there must exist welldefined communication links between those that manage a particular situation and those that are directly or indirectly involved as well as with the surrounding society in some scenarios the infrastructure and communication network could also be damaged which make the situation even worse from a crisis management perspective it certainly helps greatly if the people involved share the same awareness of the situation therefore the collection and sharing of information between stakeholders further increases the cooperative capability between public private civicand military organizations a vastly different application that could benefit by integrating sensors and social network technology is match making where the objective is to alleviate the process of meeting people with shared interests social networks have already been developed in order to facilitate match making however such networks can be further enhanced using sensor technology for example to indicate the proximity of people with common interests finally we would like to discuss the social computing paradigm in relation to a maritime surveillance system one of the challenges with such a system is to perform automated anomaly detection such a highly advanced system has to utilize distributed computation from several sources to detect and visualize outofthe ordinary behavior to aid operational decisions ports and coastal areas in particular present many challenges such as the difficulty to observe and assess its domain with respect to vessel movements activities intentions and ownership hence it is imperative to make the best possible use of all available data whether these are from sensors direct observation open source information or from the vessels even though such data can be partial and unreliable the increased use of osns and the amount of open information that is available on the internet shipspotter information and new sensor information available from eg smartphones opens up new opportunities for data and information fusion based on actual scenarios we have initially discovered that information fusion from open sources improved the capability for early identification of malicious vessels this discovery has for instance helped the swedish coast guard to monitor the right vessel at the right time and increased the time window to prepare necessary actions before the vessel arrives at the harbor therefore we consider open source information and osns as a valuable and complimentary input to the ordinary surveillance systems used by the authorities today iii security limitations current detection and prevention security solutions in opportunistic sensing and pervasive computing usually work by distinguishing malicious and benign pieces of data program or behaviors and information flow traces these approaches lack in diversity are automated and target a particular defined threat therefore we would like to elaborate on why we believe certain security solutions are not keeping up with the current generation of attackers the current communication platforms as well as many applications do not provide enough controllability for its end users today each communication device receives a routable identity eg an ipaddress it is not easy to make the address unknown to the network if it is an ipaddress you are always visible for a denialofservice attack another issue in communication is trust between parties when devices or users communicate both parties should know how much trust they share this trust value could then be used to handle the message differently because of the lack in trust determination we believe this is a major reason for having so many largescale attacks in the networking community from the perspective of the physical sensors it is necessary to consider the tradeoff between performance and security due to the limited resources sensing could also contribute to new privacy threats because sensors will be carried by people that could trace human behavior and positioning remember that in opportunistic sensing the users might not always be fully aware of ongoing monitoring thus introducing new privacy concerns from a system security perspective there have been previous efforts on designing intrusion detection systems 13 for pervasive computing idss can be broadly divided into three classes misuse detection anomaly detection and specificationbased detection the problem with these systems is that they cannot detect new unknown attacks anomaly detection simply tries to look for behaviors that deviate from normal and expected behaviors statistical techniques are used to infer an anomaly however this can lead to false positives these schemes are also sensitive to the choice of the threshold to determine an anomaly choosing a stringent threshold may trigger a large number of false positives if the threshold is loose then attackers will be able to evade detection moreover reputation systems have also received some attention 14 in most of these efforts the idea is to increase or decrease the trust associated with a neighbor node based on observations with regards to the node unfortunately the behavior of a node cannot be examined in isolation iv identifying the gaps although the aforementioned solutions have proven to be successful for particular types of threats the computing paradigm from which they stem from does not seem to keep up in defeating the new and creative generation of attackers that is motivated and supported by a growing underground economy we ask the question of what is missing as described nearly all current security models work by distinguishing trusted from untrusted pieces of data and program behaviors these approaches are automated rigid threatspecific and are lacking in diversity of operation moreover with the shift to the webbased computing paradigm 15 where users are meeting most of their computing needs through a web browser the task of distinguishing trusted from untrusted information automatically becomes much more complex leveraging social trust to distinguish a continuum of trusteduntrusted values can add flexibility to security solutions which is important in order to thwart attacker strategies by making it harder to predict a certain host behavior in the face of a particular threat we believe that human collaboration and its intrinsic definition of trust is key to move towards a new socially aware paradigm for trustworthy opportunistic sensing trust is dynamic and subjective and will most probably change or fluctuate across time depending on real life relationships between individuals we believe that trust is not only a technical issue but it also depends on social behavior from real situations therefore more types of social research need to be integrated into the future internet design and sensor networking in order to mimic real human communication v key trends in the last few years we have observed three key trends the first trend is the rise in popularity of osns as an example facebook is reported to now have about 500 million active users and this number is still growing secondly we observe the increase in complexity of the security landscape and modus operandi of attackers the current generation of attackers is extremely creative financially or politically motivated and organized traditional security models based on distinguishing trusted from untrusted pieces of data and program behavior continue to face difficulties in keeping up with the level of sophistication and ingenuity of such attackers thirdly we recognize the fact that there now exist new technological platforms and embedded sensors in mobile devices coupled with wireless communication stacks that put powerful sensor technology in the hands of the individual these new sensing capabilities stimulate the users to interact and share information within their social networks and thus help in transforming the traditional internet from a technical environment into a social platform however we note that these capabilities also increase the demands for privacy and security approaches in order to maintain a trustworthy communication architecture vi integrating social and sensor networks opportunistic sensing tends to integrate communication more closely with human behavior therefore the integration of sensors with social networks will lead to new possibilities to share realtime data and more useful applications when referring to sensors and sensor data in this paper we do not limit our ideas and the discussion to encompass only the typical sensor which is arguably the physical sensor but also consider other types of sensors the cyber sensor is one such example and its functionality can be described as that of sensing online digital information which in turn can comprise media content written text or details concerning social interactions consequently individuals can participate in events and campaigns originated by other users according to common interests and make use of the social links and communities offered by innovative social networking tools the recruitment of individuals to sense the personal environment will be the determinant factor for the success of their outcome therefore it is crucial that the initiator of campaigns either being organizations or creative individuals find the needs that motivates participation and activates devices into sensing mode osns have in this case proven to be a popular participative web tool and have caused a shift in the internet design and function with regard to connecting people we expect a great interest to bring social networks and the physical world one step closer this integration could lead to innovative applications that can sense context of the user with a higher accuracy thus providing a more personalized solution vii research challenges with hybrid networks sensing technology creates new opportunities for collecting and analyzing information with the growing ubiquity of the internet and osns the exchange of information has also increased on a global scale for some the exchange of personal information via technologies such as blogs instant message sms or social network applications has become a primary mean for human interaction however the integration of opportunistic sensing and social information has created a few challenges and opportunities as follows a interception and manipulation of online social informatics most users will engage with several application that provides different functionalities to collect analyze andor communicate data most likely the majority of the applications are in fact developed by individual developers that you have little information about therefore to ensure that social informatics are retrieved properly and securely it is important to design a system that enhance the management of social data 16 one way to solve this issue is to log the activities of applications to assist the user with valuable information in making more secure decisions users should then be able to configure certain settings to minimize potential privacy leaks etc in general such a system would work as some sort of a firewall controlling outgoing and incoming social informatics the davis social link research group has created such an infrastructure called faith to provide more trustworthy and flexible services to osn users 16 faith itself is a facebook application but works as a proxy between users and facebook it can hook other applications and provide services to the applications currently faith has about ten different applications of various kinds and it is running on the protogeni 17 platform faith provides several major functions such as privacy shield and anonymity social network structural analysis and transformation and application behavior profiling and social influences in general these functionsapplications are able to monitor and log sensing applications to perform anomaly and intrusion detection users can also customize the api to their personal information that an application can call moreover simplifying and automating the process of creating privacy policies 18 and determine how well an osn application conforms to the users privacy settings is further presented in 19 b largescale online knowledge collaboration human users play a critical role in obtaining a trustworthy system or network the employment of online collaboration may for example help in decreasing the gap between experts and novices with regard to security and privacy issues consequently largescale social networks could serve as a valuable way for novice users with a limited knowledge of security to improve their awareness it is therefore important to add the role of human users into the trustworthy computing model thus yielding a collaborative model it has already been shown that different groups of users can be identified by performing data mining on online collaborative data 20 we believe that the incorporation of human users can make a significant improvement in terms of trust and security one particular challenge is that the widespread lack of security awareness causes users to make poor decisions online some of these decisions are difficult to prevent using existing software solutions we argue that social informatics can bridge the gap in awareness by providing good collaborative models that depend on social trust and which allow users to defend themselves more effectively against different attacks zhao et al 21 present such a collaboration model that can further be developed and used in an opportunistic sensing system to obtain a neutrality policy from the injecting sensors or users this is an important issue for trustworthy collaboration in a large scale and open network environment since conflicts among users and dissenting opinions could give rise to unreliable content another important issue is how to leverage the power of social networks to automatically manage reputation and trust within a network c the sociallyaware operating system each of the devices in an opportunistic sensing system will contain an operating system and we believe that the os should not merely manage processes memory and io devices syntactically applications and the os should become sociallyaware and leverage social trust to enhance the robustness and diversity of their security mechanisms we envision a model that would allow osn users to assign trust values to other users and pieces of data that can be consumed by a sociallyaware os and architecture this would allow finegrained trust decisions about data that take into account user context thus adding sophistication and diversity to a host behavior with the integration of social and sensor network we envision an architecture for the os with the following components an extended facebooklike osn infrastructure that maintains not only user profiles and their social networks but also an optional trust repository per user users that can assign trust values to their friends in a privacypreserving fashion and feed their trust repository with trust values for objects such as urls ip addresses files email addresses and a sociallyaware os capable of retrieving and managing trust repositories locally and exporting a trust interface to user applications these applications retrieve information from a user trust repository to make better decisions about the security or trust level of the objects they access the sociallyaware os also leverages the trust repository data to employ strong and finegrained security policies about processes files modules in the systems and to propagate trust values in collaboration with the architecture layer through a virtual machine by employing dynamic information flow tracking systems 22 d user relationship controllability hijacking and identity thefts attacks have caused severe problems over the years these attacks can be used for impersonation gaining illicit access into target networks execute anonymous attacks embezzling sensitive data and many more malicious activities how do we handle the situation where two users or sensors claim to have the same identity for instance on february 24th 2008 pakistan telecomm announced a more specific ip address of youtube to its border gateway protocol peers this hijack attack caused inaccessibility to youtube from a significant portion of the internet for over two hours this attack can be characterized as two autonomous systems simultaneously announcing the same related prefixes the resolution is always which as is truly authorized to announce a prefix if any public key infrastructure domain name server or even a web browser is compromised our ground truth might not be the real one any more with this in mind our vision is to allow any sensor or user announcing them as any name or organization following our ongoing research and the social computing paradigm we believe that the relationships and the social paths in the network are key to thwart user relationship controllability viii the socially aware opportunistic sensing system for the next generation of sensing systems we envision designing an architecture based on the control and management of trustworthy social computing and providing socially aware network services a socially aware sensing system is about the relationship between social informatics and trustworthy computing at the same time as we enhance the trustworthiness for an application we simultaneously need to ensure that whatever social informatics is being consumed and processed we will not compromise any of the users privacy requirements figure 2 shows the different layers for the envisioned socially aware opportunistic sensing framework the lower layer contains the different sensors that could either be located outside or embedded in the sensing device in case of multiple sensors a meta data access point performs data fusion for the above layers to build a trusted social relationship path between collaborating sensors protocols like karmanet 23 could be used to create judicious forwarders and cut off malicious nodes and adapt to dynamic changes in behavior depending on the type of sensing a specific application to perform the opportunistic task will collaborate with the osn and make use of the available social informatics and sensor information this integration of social and sensor networks creates a highlevel trustworthy and socially aware system for individual users we further envision a future in which there will be open application programming interfaces for developers to integrate the sensors with applications in connection with social networks developers with a novel idea and some basic programming skills can quite easily create innovative applications today there are several hundred thousands of applications for the facebook community there are several research challenges in the design and development of the framework presented in figure 2 for instance how do we determine the appropriate boundary for social informatics and how do we quantitatively measure the value of social informatics how do we balance the concern of privacy and anonymity by introducing a socially aware system how can we make sure that we do not create any new or unexpected vulnerability finally what should be the process for the sensing and social community to form a converging and collaboratively decision of how to obtain a high level of security ix conclusion the development and widespread adoption of online social networks have already changed the way people interact and share information by combining physical and cyber sensors with online social networks it is possible to more closely mimic realworld interactions and situations this new type of hybrid networks can be used in a multitude of domains to for example monitor individuals enhance communication capabilities and to increase collaboration efficiency in crisis management however these hybrid networks also present challenges and issues that need to be addressed especially in terms of new forms of security threats even without sensor input online social networks have already been shown to be prone to identity theft and it has been argued that individuals are exposed to government agencies and companies in a manner which compromises privacy moreover the hybrid networks may also be more susceptible to hacker attacks for example if one system component is hacked several dependent components may stop working or could at least be compromised at the same time it is reasonable to argue that many of our currently existing security threats may be resolved by combining sensors with social informatics since we may be able to obtain better a means for determining trust values between communicating parties finally by incorporating the role of human users and social informatics it will become possible to increase the diversity in host behavior which would likely decrease the success rate of attacks and thus result in a significant improvement in cyber security

in recent years technological advances have lead to a society with communication platforms like iphone and kinect xbox that are able to inject sensing presence into online social networks osns thus it is possible to create largescale opportunistic networks by integrating sensors applications and social networks and this development could also promote innovative collaborative cyber security models in this position paper we discuss how social informatics will play a crucial role in trustworthy pervasive computing with regard to security our primary computing paradigm is still about processing information content only in order to make decisions given the availability of both digitized social informatics and sensor content we now have the option to examine these sources simultaneously we refer to this new era as the social computing paradigm and we argue that it could be particularly useful in conjunction with opportunistic sensing

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introduction this article examines whether a curricular model built on indigenous knowledge systems is possible within lis education 1 this way of learning would be more than a defined course of study it would be an ecology or educational environment built upon the perspectives of native peoples while incorporating compatible key values of lis particularly those associated with diversity an indigenous ecology model is tied to social justice through its methods aims and service audience to start the article sets the stage for introducing an indigenous ecology by defining the concepts of information ethics social justice indigenous worldview and indigenous ecology included is a brief discussion of selected theoretical concepts within social justice an understanding of indigenous worldview points the way to conceiving a space the indigenous ecology where indigenous thought can form the basis of praxis this definitions section is then followed by an overview of the methods of analysis that might be used to examine the intersection between social justice values and an indigenous ecology next the potential of an indigenous ecology is applied to the context of lis education disciplinary domains finally the article concludes with strategic actions in the form of curricular products that can be used to incorporate an indigenous ecology into presentday lis curricula this article therefore argues that it is possible for lis programs to create an effective learning environment that not only reflects indigenous worldview but also provides a centering point for understanding comparable lis and social justice ethics values epistemology methods techniques service and practice in order to reach that conclusion appropriate critical methods must be employed to develop such a model following nardi odays call for readers to become involved with information ecologies through working from core values paying attention and asking questions this article employs a heuristic inquiry involving the three phases of immersion acquisition and realization this mode of inquiry is a reflective and interpretive process of conceptual analysis that involves the following commitments close reading of the professional literature on social justice within lis and indigenous pedagogy years of conversations with and direct observation of indigenous and nonindigenous lis professionals in formal and informal settings engagement in socialaction education in the areas of lis public service and indigenous librarianship and personal cultural affiliation through the process of understanding the impact of ones interaction with the world these methods are qualitative and multidimensional aligning with and building on both a formal literature review and lived experience the methodology described here also follows indigenous processes similar to those described by linda smith such as story telling celebrating survival indigenizing intervening connecting reading envisioning reframing networking naming creating and sharing these multiple processes triangulate and as with many other subjective methods the results are filtered through the humanasinstrument screen the end result is a condensed and usercentered view of the lis concepts of information ethics information justice and progressive librarianship that is based on the lifeways and beliefs of indigenous peoples such a view is similarly aligned with the key concepts of equity utilitarianism fairness and distributive justice within social justice theory and practice definitions mason reminds us that a profession is defined by four aspects or pillarsits special theoretical knowledge its procedures or methods its history and its ethics this section of the article is concerned with the fourth pillar ethics as a belief system the overall goal of this focus is to determine which aspects may be shared among the ethical systems of lis education social justice theory information science and an indigenous worldview the section provides some crucial definitions for such an examination by discussing the intersection between social justice and indigenous worldviews considering who is indigenous and introducing the concept of an indigenous ecology these parameters are defined below in terms of information ethics and social justice indigenous worldview information ecology and indigenous ecology information ethics and social justice a discussion of social justice within lis can start with a consideration of the place of values or strongly held beliefs when examining publications codes approved by professional organizations and beliefs espoused by those practicing in the information fields koehler found that it is difficult if not impossible to express a single set of values across the information professions perhaps the best indicator of professionally held values therefore is through their tangible expressionsethics which are illustrations of applying values preer simply states ethics is about choices in other words ethics are the boundaries that help to assess and guide whether actions are correct or incorrect right or wrong ethics are the way things are done and these ways derive from practice the domain of information ethics is specifically where ethical concerns touch on some aspect of information including its creation organization and use martha smith sees information ethics as a branch of applied ethics these are actual situations that require us to make good right or appropriate decisions according to sturgis some of the primary topics discussed in the realm of information ethics include intellectual property user privacy and serving the socially excluded this last example indicates a potential link between information ethics and the area of social justice defining social justice however is not an easy task because of its amorphous nature and wide applicability social justice can be seen variably as an activity a philosophical stance a value system or a process and can also be understood as an analytical research lens an objective a call to activism or even an unwanted attempt at social engineering although the term social justice may have many differentand sometimes conflictingmeanings to different people the concept is still very important to several fields of research and practice as a way of thinking through these various definitions britz introduces several categories of justice that could be applied to any setting recognition enablement reciprocity participation distribution contribution and retribution most definitions of social justice incorporate one or more of these categories and specifically address the actions of righting wrongs restoring balance and extending benefits to the deserving the following definitions offer a few examples • social justice is the application of general principles of justice to the social order • social justice is when society can be so structured that inequality disappears • the term social justice implies fairness and mutual obligation in society that we are responsible for one another and that we should ensure that all have equal chances to succeed in life in societies wherein life chances are not distributed equally this implies redistribution of opportunities although the shape that such redistribution should take remains contested • social justice is a process and can never be fully achieved in addition to these definitions social justice can be interpreted through specific disciplines for example silver offers this definition from the perspective of property rights the distribution of produced objects among individuals in a society is just to the extent that the control over these objects is congruent with property rights odegard vereen interpret social justice within the field of counseling as a process of acknowledging systematic societal inequities and oppression while acting responsibly to eliminate the systemic oppression in the forms of racism sexism heterosexism classism and other biases in clinical practice both on individual and distribute levels social justice is similarly a core value for social workers who seek to resolve conflicts between clients interests and the broader societys interests in a socially responsible manner consistent with the values ethical principles and ethical standards of the profession finally social justice is also a qualitative feature that can both describe the practice of lis and serve as an approach to conducting research on and within lis lis can put its own stamp on social justice by extending information justice beyond attention on the individual to attention on wherever information is found and expressed martha smith describes the goal of global information justice as being to conserve nature and to preserve humanity through the creative uses of the technologies of information knowledge and memory using the practices of rights responsibilities and caring connections attention to social justice issues is also seen within lis in phrases such as progressive librarianship which civallero defines as a movement that supports and encourages the free access to information the respect of the typical cultural structures of each community the use of imagination in the management of resources the denial of established and accepted models of service and the spread of the knowledge to achieve a wellbalanced and egalitarian development of human societies thus lis supports a unique disciplinarysituated take on social justice just as the definitions of information ethics and social justice are broad so too are the research areas and associated theories within these concepts theories can be generally defined as generalizations that seek to explain relationships among phenomena as a set of variables that may explain and predict another variable or as articulated sets of interrelated constructs definitions and propositions that present systematic views of phenomena according to david smith however theory is an intellectual construct that enables us to make sense of the world or part of it the way it is or ought to be based on this definition smith organizes key theories of social justice into two categories mainstream theories and theories that are in reaction to those mainstream theories tyler boeckmann smith huo additionally define the four eras of justice research • relative deprivation which is concerned with examining concepts such as expectations and comparisons with others • distributive justice which examines issues like equity and interdependence • procedural justice in which research centers on considerations such as fairness and satisfaction • retributive justice which is concerned with aspects such as moral reasoning and blame attribution these four eras define the key areas of investigation within social justice and provide a point of comparison with theories within lis in comparison with the social justice research typology theories within lis are extremely broad in their content analysis of over one thousand articles published in six lis journals pettigrew mckechnie identified over one hundred theories arising from the field of information studies while lis theories of social justice are still underdeveloped rioux suggests some initial assumptions that can assist in considering related theorysuch as social justice theorywithin lis his second assumption that people perceive reality and information in different ways often within cultural or life role contexts provides a clear bridge between considering social justice within lis and in indigenous worldview the topic of the next section and as williamson advises there is no reason why researchers cannot draw on more than one body of research theory to underpin their own research thus even though investigations within lis are explained by many theories there is still room for such research to be informed by social justice theories as well grover glazier present a model for how theories are built by moving from phenomena to their symbols definitions concepts and propositions then to hypotheses or research questions then to three levels of theories and to paradigm finally the last step of this model is the move from paradigm to worldview librarianship has a professional worldview speaking of the development of the field from its nineteenthcentury beginnings preer describes this specific belief system of librarians animated by spirit of service professionals share a worldview shaped by their common professional training and experience notably using this model of understanding theory allows the concept of worldview itself to be considered as a type of theory although there are many different types and examples of worldviews being used analogously to theory the next section will focus specifically on a single worldview and its relation to social justice and lis education that is indigenous worldview indigenous worldview in considering the intersection of social justice with indigenous worldview it is useful to pause in order to consider the meanings and traits of indigenous that serve as this articles foundation most writings about indigenous peoples begin with an explanation of who they are and what names are used to refer to them the question of who is indigenous can also be discussed in opposition to common questions such as are there any indigenous people and isnt everyone indigenous while offering this explanation for native identity indigenous communities know who their people are in this article indigenous is used to refer to the original inhabitants of the land and their descendants who might also be referred to as native first nations or first peoples aboriginal indian or american indian in the continental united states or by specific tribal names this indigenous orientation is not only an affiliation with a specific constituency but is also a reflective process of seeing the world philosophies behaviors customs traditions and even identity are the basis of any worldview including an indigenous worldview grover glazier further define worldview as an individuals accepted knowledge including values and assumptions which provide a filter for perception of all phenomena similarly peters refers to worldviews as value systems while mihesuah extends this definition to state that worldview is a persons value system and how one interprets events and history cobern writes of seven universal categories within worldview self nonself classification relationship causality time and space in other words worldview is what you see when you open your eyes worldview explains how a person sees herself or himself it is tied to genealogy and the physical links that humans are born to and born from and it is expressed and shared communally in terms of notions of time and the connections between the present past and future worldview also speaks to spiritualitya belief in an unseen guardianship and in the place of humility in the face of the worlds gifts indigenous peoples may be very distinct in their histories languages traditions and even physical appearance and as mihesuah states there is of course no one indian world view steinhauer does emphasize that these peoples share some commonalities although there are indigenous groups all over the world and although we are different in so many ways the one thing that seems to bind us together is the common understanding of interconnectedness and that all things are dependent on each other other writers also recognize that the foundation of indigenous worldview is characterized by an emphasis on connectedness the idea that all of existence is connected and that the connectivity encompasses infuses and constitutes everything cajete additionally describes how an indigenous regard for education is a component of indigenous worldview wherein the goals of wholeness selfknowledge and wisdom are held in common by all the traditional educational philosophies around the world peters similarly defines indigenous worldview in terms of education as a philosophy of knowing that learns understands and conceptualizes by applying the patterns present in nature in the indigenous worldview this idea that land and story are alive is built on the concepts of sovereignty and selfdetermination these two core concepts assert that tribal nations can govern themselves and determine their own futures worldview then not only is reflected in traditional education models but also can form the backbone of indigenous education models today barnhardt kawagley therefore provide this advice for nonindigenous educators nonnative people too need to recognize the coexistence of multiple worldviews and knowledge systems and find ways to understand and relate to the world in its multiple dimensions and varied perspectives maori researcher charles royal introduces the potential conflicts between worldviews during such a process finally a worldview is something that lies deep within a culture and the individuals of that culture in many instances a worldview is often a given an implicit set of impressions about the world that are often left unchallenged and un discussed worldviews are invisible sets of ideas about the world that lie deep within a culture so deep that many if not the majority of a culture will have difficulty describing them worldviews typically emerge and are challenged when cultures encounter and sometimes conflict with one another royals explanation of indigenous worldview describes how difficult it is for outsiders to understand especially when even those living within the culture may not be able to describe how they see the world for nakata the two worldviewsindigenous and nonindigenousmeet at the cultural interface the intersection of the western and indigenous domains within this interface one domain does not overwhelm the other just as an indigenous person does not relinquish indigenous thought even if she or he operates in a nonindigenous scenario this process is therefore not strictly about the replacement of one with the other nor the undermining of one by the other it is about maintaining the continuity of one when having to harness another and working the interaction in ways that serve indigenous interests in ways that can uphold distinctiveness and special status as first peoples similarly for ermine the two worldviews intersect in an ethical space with the calculated disconnection through the contrasting of their identities and the subsequent creation of two solitudes with each claiming their own distinct and autonomous view of the world a theoretical space between them is opened the positioning of these two entities the autochthonous and the west divided by the void and flux of their cultural distance and in a manner that they are posed to encounter each other produces a significant and interesting notion that has relevance barnhardt kawagley likewise refer to the intersection between indigenous and western worldviews as the common ground perhaps the greatest difference between indigenous and nonindigenous worldview is found in the focus on self compared with the focus on community to the indigenous person worldview is communally shared to the nonindigenous the individuality of the self is the key aspect to understanding the processes of research and theorizing barnhardt kawagley further describe these differences arguing that the complexities that come into play when two fundamentally different worldviews converge present a formidable challenge they additionally specify that the specialization standardization compartmentalization and systematization that are inherent features of most western bureaucratic forms of organization often are in direct conflict with social structures and practices in indigenous societies which tend toward collective decisionmaking extended kinship structures ascribed authority vested in elders flexible notions of time and traditions of informality in everyday affairs unsurprisingly these two differing worldviewsthe western and the indigenousmay also conflict in lis settings this conflict will be explored later in this article specifically within a discussion of equity of access as it relates to ownership of expressions of indigenous intellectual property still despite this possibility of conflict between worldviews there are ways to break out of the mindset in which we are oftentimes stuck and although it takes some effort there are ways to develop linkages that connect different worldviews the potential of addressing indigenous worldview in lis education is therefore highly beneficial in fact such an attempt is an expression of koehlers recommendation that we should perhaps not seek to inculcate a specific rigid code of ethics but rather to expose our students to the range of thinking in the field to that end we can expose our students to important writings in the field and to the various codes of ethics of professional organizations the presentation of definitions and indigenous worldview has created the roadmap for an indigenous landscape of social justice in lis education this landscape is an ecology an environment that supports exploration of subjects and themes through a cultural lens other significant properties of such ecologies include a complex reliance on interrelationships a support of diversity among those who live within the environment a continual need for individuals to coevolve or enact change together and the strong affiliation with a locality each of these properties is supported or needed by those who work in information settings information ecology and indigenous ecology before considering an indigenous ecology it is useful to reflect on the place of the information ecology nardi oday define an information ecology as a system of people practices values and technologies in a particular local environment important features of the information ecology include its use as a social space and its incorporation of technologies information ecologies are places where people use tools and help each other in information activities through social relationships the interdependence of members within the ecology is also seen in the presence of keystone species essential partners whose presences are needed for the ecologys survival steinerová has created a model of the ecology of one public service area within information studies information literacy she places the individual who brings his or her socialcultural connections as well as physicality in the center of the model according steinerovás model the emphasis is put not on information skills but on interconnections of people and information and on ways of integrating information use into the natural human information environment the individual displays information literacy in traversing the everyday information environment domain he or she conducts the learned information literacy actions within the context of accepted values with tools appropriate for the task and with the support or awareness of his or her community the information literacy activities come about through the linkage of internal processes and knowledge capurro describes the challenges of developing such an information ecology the ecological challenge in our field is to find the right balance between overcoming and preserving or in other words between the blessings of universality and the need for preserving plurality not only for its own sake but also because human problems and solutions always arise within specific situations and need specific deliberation his call for locating the balance within the ecology connects with the concept of the indigenous ecology a space created for and by indigenous peoples but also the place of nakatas cultural interface in comparison with these descriptions of the information ecology in the indigenous ecologywhile it is also a social placethere is less emphasis on tools than on the relationships between people and their connections to traditional knowledge for example an indigenous ecology that supports nativelanguagelearning may consist of three strands or braids critical literacy local knowledges and living relationships the following explanation of indigenous knowledge provided by the living knowledge project illustrates how this concept of knowledge is interwoven into the concept of place indigenous knowledge has become the accepted term to include the beliefs and understandings of nonwestern people acquired through longterm association with a place it is knowledge based on the social physical and spiritual understandings which have informed the peoples survival and contributed to their sense of being in the world indigenous knowledge goes by many different names such as traditional ecological knowledge indigenous peoples knowledge and even folk knowledge while indigenous knowledge sometimes contrasts with scientific knowledge it can also be complementary and provide supplementary information about the world kallard refers to indigenous ecology as traditional ecological knowledge a matrix of three interconnected ways of knowing that are both contextual and processoriented these three knowledge systems encompass knowledge of practice knowledge of interpreting observations of practice and knowledge based on understanding the institutions in which learning takes place thus an indigenous ecology can be understood as both a space and a system that confirms a connection to land through the process of story story is the life of the individual set within the history and traditions of the community story documents the past while adding new actions to the record thus these new stories contribute to a collective story in which every indigenous person has a place specifically the indigenous ecology is the place where learning takes place within this indigenous ecology the ideal process of this learning is a dialogue and political negotiation of diverse perspectives and interests rather than the idea of intervention in a mechanical system of feedback loops the concept of the indigenous ecology as learning space in lis is illustrated later through several cases of potential curricular activities consideration of an indigenous ecology is beneficial even in locations far removed from tribal homelands thus the indigenous ecology as learning space can be effective even if the learners are living far from native communities an indigenous ecology that is pervasive and geographically flexible mirrors the locations of native peoples within the united states while the general perception of tribal homelands is that they are rural and remote 78 percent of american indian or alaska native peoples live outside of areas that would be considered native home areas according to fettes indigenous communitybased education can usefully learn from attempts to define and implement community education even in settings far removed from the indigenous context therefore in the interest of best serving these peoples all educatorsincluding lis educatorsshould consider how they may best implement an indigenous ecology approach within their own teaching practices such a conscious attempt to integrate indigenous and western worldviews within an educational ecology is aligned with the values and goals of social justice theory for lis educators in particular many elements of an indigenous ecology can also overlap with the elements and values of the information ecology methods of analysis for research in the indigenous ecology this is a useful place to consider approaches that might be appropriate in developing a concept of indigenous ecology and in evaluating what a future indigenous ecology would look like in terms of the field of lis until the 1980s students and scholars of only a few academic fields demonstrated an awareness or interest in indigenous ways of knowing these fields were primarily within the social sciences concerned with the study of groups such as sociology anthropology and geography by the 1990s interest in indigenous ways of knowing and representations of indigenous knowledge was seen in a broad swath of disciplinary areas including ecology soil science veterinary medicine forestry human health aquatic resource management botany zoology agronomy agricultural economics rural sociology mathematics management science agricultural education and extension fisheries range management information science wildlife management and water resource management since the 1990s there has been great interest in acknowledging and advancing indigenous research approaches in her groundbreaking text decolonizing methodologies research and indigenous peoples linda tuhiwai smith describes the need for methods that are more reflective of indigenous worldview and for more research conducted by indigenous researchers she states that the term research is inextricably linked to european imperialism and colonialism and argues that the word itself research is probably one of the dirtiest words in the indigenous worlds vocabulary this dirty word also denotes the sometimes painful decision that native scholars have to make when choosing between following western models of science and serving tribal communities peters explains why indigenous researchers need to pursue approaches that reflect their worldviews for an indigenous person research is not simply about validity reliability or getting information from others it is often described as following the circular way of the indigenous paradigm and thus it may also be about sharing the sum of what we each come to know through our own life experience and relationships with one another thus an indigenous ecology within lis would also acknowledge and employ methods that respect indigenous worldviews the interest in indigenous knowing also coincides with the expansion of interest in qualitative research methods in lis duff et al describe the attributes of qualitative approaches within current lis research concluding that indeed there may be a place for case studies anecdotal evidence and ethnographic approaches in studies of impact these approaches are in line with the advancement and advocacy of critical qualitative research in indigenous studies kawagley a yupiaq educator and researcher clearly describes the critical differences between western and indigenous views of research in western thought the objective way of knowing has the greatest value truth is assigned to what is visible explored scientifically and tested against research questions presented as hypotheses kawagley continues subjective knowledge is considered less reliable because it is not verifiable through the senses the yupiaq word tangruarluku which means to see with the minds eye transcends that which we can perceive with our endosomatic sense makers and illustrates how a native perspective may provide a way of bridging the socalled mythical subjective world and the objective scientific world here kawagley explains how indigenous worldview or beliefs inform not only daytoday life and interactions but also study and interpretation to give credence to the range of phenomena that will need to be addressed from both the yupiaq and western perspectives it is necessary therefore that both modes of inquiry and sense making be incorporated thus kawagley proposes a triangulation of more than one method of study wilson further explains the factors indigenous researchers consider in conducting their studies he argues that research must use relational accountability that is must be connected to or a part of a community if it is to be counted as indigenous an indigenous research model would therefore involve patient observation through participation over a long period of time reflection on things one saw and heard and unobtrusively informally checking out tentative conclusions with community members additionally ties to the tribal communities are strong in indigenous research as evidenced through weberpillwaxs assertion that if my work as an indigenous scholar cannot or does not lead to action it is useless to me or anyone else such indigenous research approaches are felt by indigenous researchers to have benefits for tribal communities for example burns doyle joseph krebs argue that indigenous research methodology offers expanded systems of knowledge and ways of knowing that hold potential for sustainable research practices with global applicability in the twentyfirst century similarly in writing about social work research with maori people eketone walker summarize the role of the researcher as being properly reflected in the researchers conduct and the way he implements the research that enhances the prestigemanaof the participants indigenous methodologies can therefore ultimately be defined as research by and for indigenous peoples using techniques and methods drawn from the traditions of those peoples blended or negotiated understandings of research methodologies are possible rather than assuming a dichotomous usversusthem take on the possibility of a science within indigenous worldview to this end steinhauer summarizes the agreement that most western research methods are appropriate for use by indigenous researchers as long as they honor respect manifest and articulate an indigenous world view native peoples have evolved indigenous science structures that hyperextend science to embrace everyday life and the mixing of multimodal and multidisciplinary learning recent writings therefore point to the need to recognize indigenous ways of study and to embrace the benefits of employing a fusion of methodsincluding participatory research indigenous methods and those based on western or white studies values and protocols within the information ecology and the indigenous ecology an examination of the values of lis opens this section wherein these values are presented as being similar to the values connected to the information ecology this discussion is then followed by background on indigenous core values and protocols that guide behavior within the indigenous ecology finally two key action areas within the information ecologydiversity and accessare examined in depth in order to illustrate the differences between their western orientation and the perspective of indigenous thought values within the information ecology education for the lis professions is interpreted locally and reviewed nationally it is also reflected in the research and service of the faculty and in the careers of graduates from lis programs the mission statements of selected lis programs therefore demonstrate the broad aspirations and multidisciplinary interpretations of the field lis programs are involved in understanding conducting research on and educating students on shaping the way information is produced analyzed and preserved and with planning implementing and promoting the preservation organization and effective use of societys recorded information and ideas they also believe that the collection organization retrieval preservation management and dissemination of information resources enrich cultures within society and promote equity diversity accountability and intellectual development in pursuit of these beliefs these programs therefore follow a multidisciplinary focus on issues of information access and equity sec 3 their aims are broad and extensive focusing on explor the nature of information and its use the conceptual foundations of information organization the information needs of diverse people in a range of contexts sources of information to meet these requirements and the cutting edge technology to store and retrieve information all in the context of the traditional values of librarianship including intellectual freedom and equity of information access all of these lis programs express their support of professional values such as diversity access and equity within the realm of understanding information and its use underlying the local development of curriculum and a professionwide research orientation are affirmations of key values and codes of ethical behavior in librarianship in particular the core values are generally service access protection of confidentiality and avoidance of conflicts of interest the oldest and largest professional library organization the american library association has three main documents that express its foundational beliefs the core values of librarianship the code of professional ethics for librarians and the core competences of librarianship the core values of the ala summarize eleven primary beliefs including the public good and social responsibility the ala has had a code of ethics since the late 1930s the latest version is primarily a list of recommended behaviors for library workers additionally the core competences which were approved by the ala council at its 2009 midwinter meeting identify eight areas in which students from alaaccredited masters programs should demonstrate knowledge and mastery in addition ala has delineated eight key action areas or priority topics some of which match the eleven core values the key action areas are advocacy for libraries and the profession diversity equitable access to information and library services education and lifelong learning intellectual freedom literacy organizational excellence and transforming libraries later in this section two of alas key action areas diversity and equitable access to information and library services are used to present the parallels between the lis professional worldview and an indigenous worldview as described above in the definitions section diversity and equitable access are also values shared by social justice theory therefore a potential social justice approach to integrating these worldviews within lis education and practice can be understood through these two key action areas indigenous core values and protocol while lis values are tied to a professional identity indigenous values are tied to a cultural one gaywish clearly explains this concept of a shared indigenous cultural identity despite the vast diversity in geographic location language culture and social structure aboriginal peoples share many of the same values which although contained in the cultures of other peoples are philosophically distinct to aboriginal cultures native cultural identity is seen in such details as a shared sense of humor respect for elders and for the achievements of tribal members desire to meet and learn from other tribal members and interest in furthering knowledge of ones cultural expressions such as the indigenous language and history like ethics the indigenous worldview is also guided by the parameters of behavior for indigenous peoples these guidelines are referred to as protocol protocol is the code of behavior within the indigenous ecology that allows a space where ethics rights and values can infuse disciplinary thought in native circles protocol is also equal to etiquette or custom according to jacob protocol in the indigenous sense is ingrained and largely unspoken and protocols are cultural guidelines and safetynets unique to each society still indigenous protocol is not entirely synonymous with library ethics in writing about the latter preer notes that the ethical requirements of service are constantly in motion as our practice and our understanding change she further argues that we have noted that our understanding of ethics is constantly deepening and therefore any code merely captures the ethical obligations of the moment and represents an incomplete definition of service these views of ethics are in contrast with those of indigenous protocol indigenous protocol guidelines for example have historical and traditional founding they may explain behaviors that have taken place for centuries generally discussion of protocols is not based on the desire to make changes but instead focuses on their interpretation furthermore among indigenous peoples values such as reciprocity responsibility relationship and respect are described as both personal attributes and goals for interpersonal contacts other examples of such personal and interpersonal values within indigenous protocol include the following • visionwholeness spirit centered respectharmony kindness honestyintegrity sharing strength braverycourage wisdom respect humility • personal differencesrespect quietness patience open work ethic mutualism nonverbal orientation seeing and listening time orientation practicality holistic orientation spirituality caution classroom discipline and field sensitive orientation native hawaiian protocols for example specifically include lokahi naauao aloha and malama kou piko alternatively the maori recognize manaakitanga or expected standard of behavior which includes the following principles • aroha ki te tangata • kanohi kitea • titiro whakarongo korero • manaaki ki te tangata • kia tupato • kaua e takahia te mana o te tangata of people • kaua e mahaki the above examples of indigenous protocol illustrate the personal nature of these behaviors other protocol may relate to direct contact with tribal members or contact with material objects and thus may clearly impact upon research studiesincluding those areas within lis research for example jojola describes accepted behavior by outsiders at tribal cultural events american indian communities have been hospitable to nonindians during public ceremonies but only on the condition that visitors leave only footprints tribal members are prohibited from divulging information about tribal customs and religion to outsiders especially anthropologists in some communities photography is prohibited in others some sites are restricted from public access and view in short following the correct indigenous protocol indicates respect for the local people if lis programs and researchers truly wish to conform to the ala core belief of social responsibility and to the key action areas of diversity and equity of access regarding indigenous peoples then lis curricula must incorporate an awareness of indigenous protocol and its role in the indigenous ecology the following sections therefore describe how such an understanding between lis and the indigenous ecology might be developed specifically through these two key action areas bonnici maatta wells brodsky and meadows note that diversity topics within lis curricula only began to be discussed in the early 1990s they further observe that more often than not the curricula reflect that these diversity topics are dealt with as mutually exclusive topics with each having a course dedicated to their specific issues while these comments provide one background on the perception of diversity within lis programs it is also important to consider the perspective of the prominent library professional organization within the field ala diversity as a key action area in lis and its interpretation in the indigenous ecology ala has a visible commitment to diversity through its formal structure specifically a committee on diversity reports to the ala council which is the organizations policysetting body ala also has formal affiliations with national library associations that focus on library services to people of color including the american indian library association the asianpacific american library association the black caucus of ala the chinese american library association and reforma the national association to promote library services to latinos and the spanish speaking alas respect for diversity is also reflected in policy statements including those explaining the organizations role in combating prejudice stereotyping and discrimination and its goals for inclusive and culturally competent library and information services resources on include information on developing diversity plans and on facing discrimination in the workplace alas most visible commitment to diversity is its spectrum scholarship program which has provided scholarships and leadership training to over eight hundred students from underrepresented groups ala also monitors the nature of its membership through an analysis of demographic data since 2005 ala has invited its members to complete a demographic survey in order to provide a snapshot of membership demographics over time the diversity counts study described the face of the profession in 2007 as that of a white woman in her midfifties three fourths of ala members completed the 2014 survey which found that membership demographics are largely stable in terms of gender and ethnicity ala members are majority female and white the importance of these data to a discussion of an indigenous ecology within lis is that the demography of the librarian workforce is greatly different from that of tribal communities for tribal communities support for diversity is both an acknowledgment of specific tribal identity and a commemoration of shared experiences with other tribes that have arisen from traditional alliances and competitions as cajete describes whether one views traditional iroquois sioux pueblo navajo or huichol ways of knowing and learning the pattern is the same unity through diversity indian people are all related tribal ways reflect a natural diversity of expression of basic principles and foundations while tribal members may share beliefs in an indigenous worldview indian tribes differ widely in tradition custom commitment and interests one rationale for individual tribal identity is the desire for official recognition as a tribe the us federal government legally acknowledges tribal differences through federal recognitionor acknowledgment that means that the federal government recognizes a tribe as having certain rights and powers of selfgovernment as well as rights to services that have been granted as a result of the tribes special relationship to the united states in summary diversity is valued within lis as well as within tribal communities while membership within the lis field is fairly uniform the leading professional organization supports shifts in membership demographics and is an expression of belief in social justice native populations vary greatly but recognize each other as also sharing commonalities next equity of access will be discussed as another point of difference and commonality between the two worldviews equity of access as a key action area in lis and its interpretation in the indigenous ecology a second strongly supported key action area among lis professionals is equity of access according to preer access to information is what library service is all about and providing access to information has become the central ethical value of librarianship and the one that is unique to the library profession the american library association defines equity of access as the goal that all people have the information they needregardless of age education ethnicity language income physical limitations or geographic barriers equity of access also means that all people are able to obtain information in a variety of formatselectronic as well as print and that they are free to exercise their right to know without fear of censorship or reprisal this belief in equity of access is also in agreement with article 19 of the un universal declaration of human rights everyone has the right to freedom of opinion and expression this right includes freedom to hold opinions without interference and to seek receive and impart information and ideas through any media and regardless of frontiers while on its surface alas statement appears to be supportive of social justice this concept is also the key action area that is potentially most at odds with indigenous views martha smith writes of the inevitable tensions that arise in the conflicts between ala key values notably around access ownership and privacy she acknowledges specifically the potential danger of advocating for open access if it results in eliminating native cultures languages and identities in the rush to conform to a global standard this tension can be understood in terms of the lack of familiarity within lis with the way in which the indigenous ecology perceives access in indigenous knowledge systems access to information may be governed by tradition and indigenous protocol for example some knowledge may be constructed through concepts such as womens work mens work some knowledge is shared only at different times of the year other content is not available to tribal members of certain ages or available only to members of certain subgroups access may also be defined situationally for example images of deceased individuals may not be exhibited or otherwise available during times of mourning nakata byrne nakata and gardiner explain this approach to access traditional access rights are located within customary law and kinship systems which authorized indigenous knowledge custodians understand and regulate in local contexts these can place age gender initiate status role and specialization restrictions on access to certain knowledge the indigenous ecology therefore contains a complex view of access that does not entirely or necessarily match up with the common lis view of access when faced with this alternative view of access nakata et al argue that despite the good will in the lis sector and the professions desire to do the right thing with respect to indigenous knowledge and peoples there is still in some places a perceptible undercurrent of apprehension that indigenous concepts of knowledge management and intellectual property protection are restrictive in a way that is sometimes contradictory to or incompatible with liberal and democratic notions of free and universal access to information and knowledge a better understanding within lis of tribal protocol can be used to provide one additional framework to access that may be perceived as less limiting and at the same time more respectful of tradition and cultural balance while there is little formal professional agreement on how librariesarchives museums should interact with traditional knowledge there are a number of relevant documents that have been created within professional communities the international federation of library associations and institutions recommends that libraries encourage the recognition of principles of intellectual property to ensure the proper protection and use of indigenous traditional knowledge and products derived from it while the advice given within these statements is publicly available the extent of awareness of it among lis educators and practitioners much less its application is unknown the key action areas of diversity and equity of access define and express lis professional values and social justice lis professional views of diversity reflect a need to prepare a workforce that reflects the communities that libraries serve equity of access speaks to the professions desire for distributive and procedural justice belief in social justice and diversity supports the potential for an indigenous ecology as an educational laboratory a concept explored in the next section education for the indigenous ecology in look to the mountain gregory cajetes ecology of indigenous education considers these sources of knowing among indigenous peoples • learning from the environment • learning from myth or story • learning from visionsexpressions of art • learning from everyday tribal community life this view of learning indicates an orientation to manifestations of the world that are physical communal spiritual and historical in the indigenous worldview education is the lifelong seeking of fulfillment cajete describes this personal journey as a process of finding face finding heart and finding foundation all in the context of proper relationship to self community and the natural world with their attention to user communities and their needs the lis professions offer practitioners careers that provide a balance between selffulfillment and social justice these sources of indigenous knowing have several parallels within lis while indigenous knowing evolved from centuries of traditions and understanding with strong attachments to geography lis also has historical groundings and connections to place first lis disciplines are location or setting based regardless of whether or not the word library appears in the name of a lis program that programs studies research and practice still consider the locationthe environmentwhere library services take place second the history myth or story of lis includes biography incidents lessons learned progress achieved and values lis traditions which have evolved from the culture of print now include the changing digital world lis myths and histories are also tied to progressive era reform and the role of gender in the workplace significantly the lis professional organizations note the contributions of individuals and continue to recognize individual achievement information professionals additionally tie their learning to innovative expressionsfrom the art of reference and catalogingorganization to the design of electronic resources as well as to the vision of dynamic leadership as a social field librarians learn from their lis professional community with their communities of users thus the lis cultural model of learning can be described as follows • learning within an environment • learning from tradition with respect for history • learning from artistic expressions of service • learning from a community of lis professionals and patrons the lis learning model is reflective of lis theory and practice like indigenous sources of knowing lis learns from what happens within its spaces as it promotes stimulates and witnesses the levels of learning that occur among members of its service communities lis actions beliefs and activities evolve from professional values the final section of this article presents suggestions for curricular products that might serve to bridge the lis and indigenous cultural models of learning advancing an indigenous ecologyroy 405 curricular products in the lis indigenous ecology the indigenous ecology is an ethical space and as the intersection between indigenous and western worldviews it provides the ecology or area of study it also serves to enable people to develop means to transform how people produce interrogate value apply and disseminate different forms of information it is in this space that productive learning can take place within lis curricula such learning supports expressions and practices of social justice along with cultural responsitivity various curricular models based on indigenous perspectives have been developed for selected examples see barnhardt kawagley 2005cajete 1994 p 203 and1999 193221hammersmith 2007 p 179merculieff roderick 2013mihesuah 1996 pp 131145snively corsiglia 2001 p 27and stephens 2000 in particular the assembly of alaska native educators offers twenty cultural standards for curriculum which are grouped under five topics • a culturally responsive curriculum reinforces the integrity of the cultural knowledge that students bring with them • a culturally responsive curriculum recognizes cultural knowledge as part of a living and constantly adapting system that is grounded in the past but continues to grow through the present and into the future • a culturally responsive curriculum uses the local language and cultural knowledge as a foundation for the rest of the curriculum • a culturally responsive curriculum fosters a complementary relationship across knowledge derived from diverse knowledge systems • a culturally responsive curriculum situates local knowledge and actions in a global context similarly hampton writes of the standards of indian education as resting on a dozen attributes spirituality service diversity culture tradition respect history relentlessness vitality conflict place and transformation indigenous teaching and learning therefore strongly emphasizes modeling and guided practice and acknowledges that cooperative learning peer tutoring and handson learning are essential strategies in merculieff and rodericks writing of an ecological approach to reviving indigenous languages for example the learning processes are expressed through indigenous ways of teaching and learning to include the following • earthbased pace cajete proposes an indigenous science curriculum that is modeled along seven directions center below above and the four cardinal directions the four directions are also associated with the four winds the four seasons doors or openings and phases of the day they have also been associated with the four elements and the four races according to hampton each direction is a complex set of meanings feelings relationships and movements this concept of the sacred circle represents knowledge of many types also called the medicine wheel this model is illustrated in the following way drawing simply begins by making a circle the circle symbolizes the continuity and connectedness of events with the added dynamism of movement superimposed on the circle are four equidistant points the points symbolically identify the powermedicine of the four directions east south west north calliou further describes the types of learning associated with each direction in the model specifying that each of the four corresponds to an aspect of humanness north with the mental realm east with the spiritual south with the emotional and west with the physical this educational model is a concrete approach to recognizing indigenous worldview employing the diversity of learning styles and content areas found within lis education what follows are four specific activities or approaches that can be brought into the lis curriculum as steps toward creating the indigenous ecology each example illustrates an energy orientation or construct stemming from one of the cardinal directions also referred to as doors from the east or eastern door observing protocol by introductions the east represents spring beginning identity culture and diversity when students answer the question who are your people they illustrate that through knowledge of self individuals become aware of underlying cultural assumptions in their background that may not have previously been examined by having the option to present himself or herself culturally and by learning style and cardinal direction specific content contributed andor technological applications utilized each student invites communication and provides the context of a future relationship from the west or western door social connections and the difficulties of life the west is fall change history education service and relentlessness lis students might remember the wisdom needed from the direction of the west when they are asked to complete coursework through collaborative learning cajete also recognizes that creative roles are associated with each of the four cardinal directions like learning styles these roles may help students to understand their contributions to group efforts as they perform as artistpoet warriorhunter shamanpriest andor philosopherteacher from the south or southern door healing emotions and language the south is the summer the place of affirmation talking or sharing circles are safe places where individuals can share their thoughts and feelings sharing circles are led by facilitators who help set the tone for the conversation and provide supportive responses individual speakers often are recognized by holding an object such as a feather or a stone the sharing circle approach enables work groups to coalesce as they come to acknowledge their shifting roles in their joint work and with each other within lis research the healing circle is similar to kuhlthaus zones of intervention that call on librarians to respond to patron needs according to various levels of mediation depending on where the student is in her or his search process from the north or northern door endurance and survival the north or northern door is the winter the place of struggle and survival coursework can bring together the energies of all four directions in the struggle forand achievement ofservice engagement this is where lis students can work directly for and with indigenous peoples through the ethical space based on protocol learning styles and using sharing circles as a touchstone service learning options might be embedded in courses or available as options for assignments individual studies practica or internships capstones or in organized volunteer efforts in engaging in collaborative work with members of tribal nations lis faculty and students need to follow protocol and should also challenge their motivations for such work summary lis educationwith its necessary balance of theory and practice its focus on evaluation assessment and accountability and its institutionbased perspectivewould benefit from exploring a connection with an indigenous ecology framework lis and indigenous worldviews share the characteristics of change a responsiveness to social and technical environments a regard for historical traditions and an ability to adapt while retaining a cultural branding lis professionals and tribal communities respect and even celebrate diversity though they differ in their interpretation of equity of access this is an essential concept in both lis and indigenous thought if a true indigenous ecology can emerge andor exist within lis then care must be taken to ensure that its emergence does not repeat colonial models of information gathering organizing and sharing nakata warns for example that the documentation of such indigenous knowledge by scientists the storage of information in databases in academic institutions whether they be gene banks or electronic networks all looks remarkably similar to former colonial enterprises which coopted land resources and labour in the interest of their own prosperity through trade and valueadding such a cooption would not be true to the belief systems of lis indigenous worldview or social justice work to prevent this outcome an indigenous lis curriculum should connect culture and learning support the contributions of the individual to the learning process while retaining a community center and be responsive to the environment linda smith describes the possibility of such an indigenous ecology in various places around the world there are small initiatives which are providing indigenous peoples with space to create and be indigenous this indigenous ecological space within the field of lis would permit the development of curriculum writings and discussion what is needed at the professional level is a process that evolves from setting boundaries through identifying drafting and promulgating definitions and differences into one that includes training examples based on input from tribal communities

this article explores whether library and information science lis education can incorporate an ethical learning environment based on indigenous worldview such a space is an indigenous ecology where relationships between people can be forged based on traditional knowledges connections between the indigenous ecology information ethics and social justice theory are drawn as a prelude to considering indigenous worldview the protocols or behaviors and values within the ecological system are described indigenous perspectives on research methods are introduced providing a background for considering approaches to study within the indigenous ecology finally several casespecific examples are offered that illustrate features of the indigenous ecology these features are mapped according to the concept of the medicine wheelcircle acknowledging that various strengths and challenges are associated with the cardinal directions the indigenous ecology provides a means for respecting diversity while reinterpreting strongly held professional values such as those related to access to information

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background australia has diverse and growing migrant populations with 190 different countries and 300 different ancestries represented 1 results from the most recent australian census showed that that up to 285 of the australian population where born overseas 2016 2 it has been well established that patients from culturally and linguistically diverse backgrounds experience poorer healthcare access and health care outcomes these disparities have been shown to exist even when cald population have similar medical conditions to english speaking patients 34 such disparities are in part due to language barriers which make communication with the health system difficult 5 how to provide accessible and quality health care is a serious challenge for the australian health system patterns of health care access among cald patients with low english proficiency highlight the experience of compromised care longer hospital stays higher rates of medical errors and poorer patient satisfaction 6 7 8 9 existing health services need to adapt in order to promote the health and wellbeing of cald populations the provision of a culturally competent health care service has been posited as a key factor towards improving health outcomes increasing the efficiency of clinical staff and improving patient satisfaction growing work highlights key organisational components that have been shown to promote cultural competency including the provision of health professional training and creating policies that streamline care and facilitate communication 10 however barriers towards the provisions of culturally competent care include a lack of value in and resources towards staff training and education as well as the provision of culturally appropriate health education materials and other support to help patients navigate the health system 11 effective communication coupled with identification of and respect for cultural differences is essential to the delivery of culturally competent care to achieve this health services need to facilitate clinician understanding of how patients from cald populations understand disease and illness view the causation and prognosis of their illness describe their symptoms understand treatment processes and how they perceive their role 12 for example some cald patients do not consider it acceptable behaviour to ask questions within the health care context as a results they are greater risk of not understanding their condition being able to follow their treatment plan nor understand their health care rights 1314 in an australian context interpreters are frequently provided as a means to overcome language barriers and help cald populations to interact with and navigate the healthcare system despite evidence showing the association between interpreter access and better health care experiences and outcomes for patients with lep 15 16 17 18 there remains an underuse of interpreters reasons for not using interpreters stems from the perceived lack of interpreter availability and increased workload when using interpreters 151920 instead health services frequently use family members or untrained staff such as bilingual or nonmedical staff to act as interpreters 21 use of nonaccredited interpreters has been shown to compromise the quality of care as they lack vocabulary to interpret complex medical terminology leading to misunderstanding and errors in translation toward key care components such as symptom identification and participation in medical decision making 2122 it is important for us to understand the impact of not providing professional interpreter services on patient health care journeys findings can identify gaps in service provision that are not consistent with culturally competent health care and inform practice improvement as part of a larger study exploring hospital related outcomes of patients from culturally and linguistically diverse backgrounds 23 we aimed to explore the experience of patients with limited english proficiency and professional interpreters in an acute hospital setting methods study design this qualitative study explored the delivery of culturally competent health care in an australian acute hospital setting a data source triangulation approach was used to increase study validity and data richness by capturing different perspectives of the same phenomenon 24 first we undertook semistructured interview across four culturally and linguistically diverse communities with regards to their recent hospitalisation and access to interpreters we also conducted focus groups with professional interpreters working at monash health recruitment occurred between may and june 2017 this project received approval from the monash health human research ethics committee recruitment patients potential participants were recruited as part of a larger study in brief patients admitted to the general medicine program at monash medical centre or dandenong hospital during the 201516 financial year who were identified as having lep and whose preferred language was either greek chinese dari or vietnamese these languages were chosen as they were the most prevalent participant groups meeting the following criteria admitted and received services from a trained interpreter on at least one occasion during an admission in the 201516 financial year with an additional admission in the same year without access to a trained interpreter were prioritised patients meeting inclusion criteria were mailed a letter of invite to the study including study information in their preferred language after 2 weeks the researchers using relevant interpreters phoned each patient to answer questions and make an interview time at a convenient time and location typically the patients home written consent was obtained prior to the interview commencing interpreters focus groups were conducted at mmc and dh recruitment was open to all professional interpreters however to maximise participation the fgs were arranged by the interpreter service site manager at each site thus fgs formed a convenience sample detailed information was given about the study time and location of each focus group and all participants provided written informed consent date generation patient indepth interviews were conducted by two researchers with the assistance of interpreters using an interview schedule 25 interviews began by asking participants to share their story of hospital admission and subsequent questions explored their experience of access to an interpreter or not the semistructured nature permitted flexibility for participants to elaborate upon or cover important topics that would not have otherwise surfaced for example the experience of feeling confusion during ward rounds 26 emergent themes informed continuing data collection and sampling continued until thematic saturation was achieved focus groups focus group methodology has been described elsewhere 23 questions specific to this studys research aim explored the experience of interpreting for patients from culturally and linguistically diverse backgrounds in a busy acute hospital setting thematic saturation was achieved analysis qualitative data analysis has been described in an earlier publication of clinician experience of language discordance 23 briefly interview and fgs were recorded with participant consent and transcribed verbatim with identifying data removed data analysis was guided by an inductive thematic approach 27 whereby the first step involved sustained engagement with the data through an initial reading and rereading of transcripts to identify units of meaning and initial codes following team discussion initial codes were used to identify key categories and the primary author merged codes in the final step emerging categories were refined and grouped together into a theme rigour was upheld through immersion in data reflexive analysis peer debriefing and consensus coding between team members and discussion with a broader team 28 coders also captured exemplar quotes supporting each theme results patient themes participant demographics are shown in additional file 1 table s1 four distinct themes emerged from the greek mandarin dari and vietnamese participant interviews included in this study these are discussed as follows 1 i dont want to complain… limitations towards advocacy many participants reported experiencing emotional distress during their hospital admission feelings of worry and uncertainty were compounded by language barriers and not being able to communicate in a common language i feel over overwhelmed i felt not able to communicate in my own language this was very torturesome 1 several participants reported that the assessment process was not clearly explained to them despite not understanding what was happening participants reportedly did not ask questions as they trusted that they were receiving appropriate care being in a hospital setting that was considered a higher standard compared to their country of origin participant reports also suggested they were less likely to complain or advocate for their needs given their limited understanding of the australian health system and awareness of their rights and responsibilities as a patient because we are unfamiliar with the hospital protocol and procedure…so we will just follow what the doctors instructions are lack of selfadvocacy was evident in most participants who relied on the hospital to arrange an interpreter for them however few participants reported being offered an interpreter participants with some understanding of english were more confident to advocate for their own needs including asking for an interpreter and expressed concern for patients who had limited comprehension of english if you cant communicate effectively i would feel a bit in a disadvantage position but on the other hand i do understand a bit of it there are other patients who dont and for them its even worse in fact the majority of participants assumed a passive role in communication with health professionals for example participants reportedly listened to information provided to them during ward rounds and other medical consults often not understanding or contributing to the conversation unless they were asked directly or prompted this led to feeling left outside of the conversation yeah there were times that the doctors were coming and saying the stuff and there was no interpreter and then i wouldnt understand what they said however feelings of being reassured by staff were reflected in participants expressions of confidence in the doctors their competence and intention whatever they offer i accept i have no knowledge in the health area so i thank to the doctor and the nurse helping me 2 if there can be interpreters present that will be the best thing experiences of access to and use of interpreters access to interpreters reportedly varied among participants and there was consensus that greater access to interpreters would have been beneficial during admission i dont want to create trouble with the hospital and also i have to face my language difficulty if there can be interpreters present that will be the best thing in contrast all participants reported that the hospital organised an interpreter when consent for a procedure was required they would call an interpreter not all the times not from the beginning but i did have an interpreter whenever i had to do scans participants who had had previous admissions to hospital often noted that their need for an interpreter has already been established and an interpreter was automatically booked alternatively other participants who had had multiple admissions and wanted to ensure access to an interpreter said their children would phone ahead to arrange with the hospital for an interpreter similarly there was a common perception that interpreters were not available after hours therefore when presenting to the hospital after hours some participants indicated that it was important to bring a family member with them who could act as an interpreter it depends when we had the admission whether it was during the day or during the night if it is at night we didnt have an interpreter… so i would take one of our children along with us several participants felt guilty about having limited english proficiency which made them reticent to request to be a burden on the health system and ask for an interpreter i feel very bad due to the fact that i have been in australia for 60 years and i cant speak english and answer a question put to me in the english language i feel overwhelmed… limited communication causes frustration and isolation participants who didnt request an interpreter or indicate when they didnt understand what was happening often suffered this was in part because they didnt want to be a burden to staff for example one participant never complained about being in excessive pain and instead relied on seeing a nurse for pain medication at the scheduled time i knew when they would come around because they would give me medication and if i was in pain i will endure it until they arrive participants noted differences in their treatment by staff as a result of not speaking english and a times felt discriminated against when nurses didnt talk to or approach them nurses would go more often to the patients who spoke english however interactions with staff and other patients who spoke their language greatly improved distress and feelings of isolation this was most notable for participants with limited family or social support or when hospitalised for a prolonged period such as for rehabilitation later on there were nurses either they can speak in mandarin or in cantonese who are on duty but then when none of them are on duty we are stuck but we have to cope with it… you have to cope with it feelings of being over looked and not involved in decision making led to feelings of frustration they dont pay enough attention they assume that i am an idiot not worth it some participants reported distressing experiences exacerbated by communication misunderstandings confusion about levels of independence meant some participants felt that nursing staff were unsupportive or refused to help another participant felt she was kicked out of hospital when her readiness for discharge was not explained if i dont understand i ask to stop as my daughter is coming the role of family members all participants stated that family members were considered integral to their hospital experiences and decision making towards health care for example if a doctor proposed a treatment regime or the need for a procedure then participants were likely to request that their family members be consulted this had the potential to significantly delay procedures and length of stay when waiting for family to visit or when an interpreter consult needed to be organised to facilitate discussion with family members if i dont understand i say no stop my daughter coming most participants were aware that by relying on family to be involved in decisions that they were placing them under stressful situations due to the challenge of interpreting complex medical information and to ensure accurate information exchange my children speak fluent english but they dont speak fluent greek especially when it comes to medical terminology and they cant explain properly… so… even if they can understand anything they cant express everything you know the way an interpreter would interpreter themes interpreter demographics are shown in additional file 2 table s2 three key themes emerged which are discussed as follows 1 constraints to accurate interpreting we are here to facilitate communication delayed involvement interpreters reported they often felt conflicted and constrained by scenarios which they perceived went against hospital policies that aimed to ensure inclusion and accurate information exchange in the first instance interpreters cited that family bilingual staff and nonprofessional staff were called upon being considered quicker and more convenient than booking their services even when they had been booked interpreters noted that staff preferred to grasp earlier opportunities to start assessments when family were visiting if staff think the daughter is here the cleaner is here that will be quicker easier staff have booked an interpreterbut when the daughter comes in before me then they staff would prefer to use the daughter rather than wait for me the interpreter further when an interpreter booking hadnt been made and they were observed to be present on a ward then interpreters felt they were grabbed by staff to provide immediate and spontaneous interpreting while interpreters obliged where they could it wasnt always possible since there were already booked for another patient or for an outpatient clinic they staff ask for me to stay back so i can tell the patients or can ask the patients a few questions about caring for them i try to family as interpreters all interpreters expressed concern regarding the ability of family members typically adult children to accurately interpret in a stressful situation accurate interpretation of medical terminology was considered difficult and interpreters felt there were no procedures towards establishing the ability of family to accurately translate before proceeding with a consult despite clear hospital processes promoting access to professional interpreters it was readily noted that both staff and family frequently overestimated the abilities of a family member to assist before involving a professional interpreter when clinicians are communicating with patients up in the ward there is an assessment made about the patients english language proficiency …and it is not necessarily the patient who is making that assessment often they clinicians incorrectly assume that the patient has a greater level of language proficiency even patients tend to overestimate their ability to communicate in english because they can go and pay for a newspaper some interpreting scenarios where reportedly more challenging than others particularly those when family insisted on interpreting despite the presence or an interpreter and when family withheld information from the patient patients children often do not have sufficient language skills on the one hand and also in other cases interpret half the truth further when family members were present interpreters reported they were reliant on the treating clinician to advise them whether to stay or not even though this contradicted policy we need the cooperation from the professional to help to work with us if the professional keeps going with the family members which is easy…every conversation we are left out overall interpreters felt if they were able to stay for a consult then they could step in to ensure accurate information was relayed and when you have a family member they dont tell it exact it is hard but if i am there and they dont speak properly then i can jump in and said no it is not there are two things not telling the truth or misinterpreting information overall interpreters observed the implications of delays in accessing their services such as the need to more accurately clarify symptoms and assist in complex family scenarios failure to involve their services in a timely fashion was perceived to be inefficient since it often required an initial assessment to be repeated or led to the risk readmission and then you start from scratch and then you feel like oh my god and the patient is already frustrated not understanding what is happening they want go home soon and if they do go home…they will be back into hospital again because the picture of their health is wrong from the beginning working with clinicians staff familiarity and confidence all interpreters expressed that their ability to interpret accurately was compromised when treating clinicians failed to use their services or were unaware of or failed to attend to cultural factors these had the potential to impact on patient care recurring scenarios reportedly involved families not informing patients especially parents the truth about their illness and prognosis or speaking on their behalf interpreters were aware if this culturally factor stemming from a families desire to support their parent and reduce fear and burden but had the potential to cause confusion they dont tell them because they dont want their loved one to know whats exactly going on it is a cultural thing another barrier to accurate interpretation occurred when interpreters perceived the information being provided to the patient by a clinician was too complicated for a patients level of insight and ability to comprehend for example interpreters felt that clinicians did not appreciate the complexity of the information being conveyed to patients towards medication or chronic disease management the thing is you cant assume that they patient know the connection between going home taking medication and staying here are the same thing but you know if you get the background you explain a little bit more as an interpreter …that helps… interpreters also felt conflicted when they perceived that patients werent given chance to speak even if that wanted to interpreters readily observed this as very disheartening from the patients point of view they staff are not allowing the opportunity to ask questions or to understand what is going on 3 concern for accurate information exchange all interpreters valued maintaining a sense of professionalism in their role as interpreters both before during and after the interpretation situation this entailed providing a complete and accurate interpretation remaining impartial and ensuring confidentiality to facilitate communication however interpreters reported that it was difficult to carry out their role when there was a high turnover staff who lacked awareness of their service or how to work with them lack of awareness of the service i think sometimes as well is that given the high turnover of staff not everyone is then familiar with how to access to service interpreters identified gaps in the skills of clinicians especially those not experienced with working with patients with lep andor interpreters highly valued skills included active listening cultural awareness resect for family involvement respect and responding to the patients needs and wishes interpreters greatly appreciated it when a clinician contacted them to clarify and confirm the outcome of a clinical consult and any cultural aspects alternatively some interpreters were proactive and would ring the treating clinician following a consult however the timing of this was difficult for them coordinate discussion this qualitative study involving interviews with patients with lep and professional interpreters highlighted barriers to the delivery of a high quality culturally competent health service a central finding of this study was that patients with lep felt overwhelmed and frustrated when unable to advocate for themselves and were not involved in decision about their own care however patients felt guilty when they didnt speak english which subsequently lead to them being passive in encounters with health professionals professional interpreters felt their services were not given priority and that family members were used to interpret in the first instance despite the potential for inaccurate information exchange similarly professional interpreters observed the reliance on bilingual staff as a convenient alternative communication strategy all participants reported the reliance on family members and untrained staff who were not skilled in interpreting medical terminology was a barrier to accessing professional interpreters this is consistent with previous research demonstrating that untrained staff do not have the skills in accurately translate medical terminology 29 further unskilled interpreters may not perceive cultural norms such as when cald patients are perceived as being shy or show agreement with clinicians even though they dont actually understand what is being said 30 this study also highlighted the experience of distress in patients when they perceived they were being overlooked by clinicians evidence highlights that dealing with emotions is complex and this is further compounded in cald patients when language barriers exist and when clinicians do not respond empathically 3132 we posit that the provision of culturally competent care requires educating clinicians to better detect the presence of psychological disturbance the delivery of culturally competent care is a challenge to many countries experiencing increasing numbers of migration and our findings echo this challenge despite legislation to facilitate the availability of professional interpreters 5 we identify key training components for clinicians working with cald patient such as developing cultural awareness involving patients in communication and information sharing and how to effective work alongside professional interpreters further we suggest that training towards providing culturally competent care also should be provided on an ongoing basis in order to sustain benefits to patients 33 and reinforce clinician behaviour 34 however given barriers to the use of professional interpreters ongoing efforts need to made by clinicians and administrative to address barriers to access and meet legislative requirements 3536 strengths and limitations we have previously reported on the outcomes of the clinician experience of language discordance 23 this study generates important indepth insight into the patient journey from a patient and interpreter perspective findings consistently highlight the need for greater access to and use of professional interpreters in order to provide the opportunity for communication reassurance and earlier evaluation and treatment where necessary conclusion as many countries experience growing cultural diversity there is need for the provision of enhanced care to patients from cald background and access to interpreters this can be promoted by training towards the effective use of professional interpreters in a hospital setting such efforts should be multidisciplinary and collective in order to ensure patients dont fall through the gaps with regards to the provision of culturally competent care additional files additional file 1 table s1 authors contributions jw completed data analysis with support from tp jw drafted the manuscript for publication and th tp contributed to the content and revision of the manuscript lt em tp contributed to working group meetings and revisions jw managed revisions literature and checking of the manuscript all authors read and approved the final version competing interests the authors declare that they have no competing interests

background culturally competent health care service delivery can improve health outcomes increasing the efficiency of clinical staff and greater patient satisfaction we aimed to explore the experience of patients with limited english proficiency and professional interpreters in an acute hospital setting methods indepth interviews explored the experiences of four culturally and linguistically diverse communities with regards to their recent hospitalisation and access to interpreters we also conducted focus group with professional interpreters working data were analysed using an inductive thematic approach with constant comparison results individual interviews were conducted with 12 patients from greek chinese dari and vietnamese backgrounds focus groups were conducted with 11 professional interpreters key themes emerged highlighting challenges to the delivery of health care due distress and lack of advocacy in patients interpreters struggled due to a reliance on family to act as interpreters and hospital staff proficiency in working with themin an era of growing ethnic diversity this study confirms the complexity of providing a therapeutic relationships in contemporary health practice this can be enhanced by training towards the effective use of professional interpreters in a hospital setting such efforts should be multidisciplinary and collective in order to ensure patients dont fall through the gaps with regards to the provision of culturally competent care

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introduction substance use is the lifetime use of any substance including khat cigarettes illicit drug use alcohol and other substances 12 substance use has increased in recent years and is a growing public health problem and a worldwide threat significantly affecting young people aged 1024 years 1 2 3 the commonly used substances globally are alcohol khat cigarette hashish and other illicit drugs like cannabis heroin and cocaine 45 for instance about 53 of people aged 15 years and above have ever used alcohol globally 67 a recent systematic review in subsaharan africa estimated the prevalence of substance use among adolescents to be 416 with alcohol being the most prevalent compared to other substances 12 in tanzania the lifetime prevalence of substance use among schoolgoing adolescents was 7 with alcohol at 45 and drugs specifically marijuana amphetamines or methamphetamines being the most used 89 in the kilimanjaro region cigarettes alcohol and marijuana were the most commonly used substances among schoolgoing adolescents 10 studies on substance use and related risk behaviors among adolescents in tanzania are scarce therefore limited data is available to inform policy and interventions adolescence marks a critical time of growth in the life course and profound changes in physical cognitive and social development 3 substance use at the early stages of adolescents increases the risk of developing addiction mental disorders and substance use disorders 16 for example in developed countries the estimated risk of developing drug dependence on cannabis uses alone among lifetime drug users who started using drugs during the adolescent period is 17 11 substance use and mental disorders accounted for 1839 million disabilityadjusted life years in 2010 especially among adolescents and young to middleaged adults aged 1029 years 12 13 14 in addition substance use among schoolgoing adolescents leads to poor academic performance reduced productivity high dropout rate and indiscipline 415 which have implications that can persist throughout the life course 16 according to the global initiative outofschool children study in tanzania almost 23 million of secondary schoolage children are out of school the reported dropout rate by 2014 among registered adolescents was 75 17 the factors are bad youth groups involved with substance use specifically smoking bhang and truancy tendencies 17 the sustainable development goals include strategies to reduce the burden of substance use among adolescents through strengthening the prevention and treatment of substance use 18 among other interventions tanzanias adolescent health and development strategy 20182022 aims to ensure the availability of preventive and treatment services that are affordable accessible and friendly to reduce the burden of disease among adolescents also the strategy recommends substance use counseling among adolescents which would require promoting communitybased youth centers and strengthening community involvement in the adolescent health strategy to improve key adolescent health care practices 19 nevertheless most existing interventions focus on sexual and reproductive health and hiv aids and less on emerging adolescent issues such as substance use accidents and injuries mental health and road safety 19 in addition studies on adolescent risk behaviors in different settings focused on one or a few substances mainly involving young people aged 1524 years and among outofschool adolescents 6916 therefore information about the burden of substance use among the schoolgoing adolescents is relevant to complement the existing literature and inform targeted interventions and potential policy decisions this study assessed the prevalence of substance use and associated factors among secondary school adolescents in the kilimanjaro region northern tanzania methods study design area and population we carried out a secondary analysis of data from a schoolbased crosssectional study conducted in public secondary schools in four districts of the kilimanjaro region namely moshi municipality moshi hai and siha districts by the institute of public health in kilimanjaro christian medical university college the main aim was to assess the risk behaviors of adolescents attending public secondary schools the study included all consenting formone students who attended public secondary schools in 2019 from the selected four districts of the kilimanjaro region kilimanjaro is one of the regions in the northern part of tanzania comprising seven districts and covering 13250 km 2 kilimanjaro has an estimated population of 1640087 people and an annual growth rate of 16 the major economic activities in the region are agriculture and livestock keeping 20 kilimanjaro has many secondary schools compared to other regions with 313 secondary schools making the region home to many adolescents who spend most of their time and days in school 21 according to the countrys profile adolescent accounts for 23 of tanzanias population 13 and 10 for the 1014 and 1519 age groups respectively 19 sampling data collection methods and tools a multistage sampling technique was used to select 3227 adolescents four districts were purposefully selected in the first stage ensuring ruralurban representativeness the second stage was a random selection of public secondary schools from all available schools in each district only formone students were included at the school level to build a cohort of repeated crosssectional surveys in the following years the purpose was to document trends of adolescent risk behaviors over four years period finally a simple random sampling technique selected students proportional to the size of each school analysis was performed on 3224 adolescents after excluding three participants aged less than ten years and greater than 19 years of age the interviews were selfadministered using the regional school health survey questionnaire adopted from the whocdc global student health survey 22 the rshs questionnaire was standardized to assess risk behaviors among schoolgoing students in tanzania and administered in the kiswahili language 8 the tool has also been extensively used in other settings 152324 the risk behaviors in this survey included nutrition and participation in physical activity personal hygiene and substance use including smoking alcohol illicit drugs marijuana khat use experiences of violence and abuse and risky sexual behaviors trained medical students from kcmuco collected data before data collection the data collectors explained the study purpose to all form one students and responded to all the questions asked before administering the interviews the selected participants were then given the questionnaires and instructed to wait for further instructions from the data collectors the next step was reading one question after another to ensure each respondent understood the question before filling out the questionnaire the process continued until the last question the data collectors made the necessary efforts to ensure privacy and confidentiality during the data collection this was done by clearly explaining to participants why this was important and ensuring spaces between participants when completing the questionnaires study variables the dependent variable in this study was substance use lifetime substance use refers to using any substance at least once throughout the adolescents life 12 the substances considered in this study were alcohol cigarette smoking marijuana khat and recreational drugs lifetime substance use was coded as yes if an adolescent reported using any of the above substances and no if otherwise current substance use refers to using any of the following substances during the last 30 days preceding the interview cigarette smoking tobacco products alcohol recreational drug marijuana khat and amphetamines the independent variables included adolescent sociodemographic and behavioral characteristics the demographic characteristics were adolescents age sex schooling district and the number of days ever missed class social and behavioral variables were parentguardian use tobacco ever had sex number of sexual partners source of alcohol frequency seen alcohol advertisement frequency parentsguardian understood your problems number of close friends social support from friends ever been bullied ever engaged in a physical fight and ever rode in a car with a drunk driver oral informed consent the headmasters from each secondary school assented to interview students aged 18 years because no invasive procedures required parental consent hence the need for parental consent was waived by the ethics committee ethical approval for the current study was sought from the kcmucrerc and obtained approval ethical clearance certificate number pg04 the institute public health director at kcmuco provided permission to use the data the study observed and protected the confidentiality and privacy of the subjects data instead of adolescent names or any personal identifiers unique identification numbers identified study participants results participant sociodemographic characteristics the mean age of 3224 adolescents in this study was 146 years and a standard deviation of 107 years more than half were aged 1014 and just over half were females most adolescents included in this study schooled in moshi and siha district councils and moshi municipality few respondents 103 reported missing class at least for four days or more selfreported prevalence of substance use the lifetime and current prevalence of substance use was 197 and 128 respectively among those who reported having ever used substances the most common substance reported was alcohol and cigarette smoking followed by khat recreational drugs specifically cocaine and heroin and marijuana the common substances reported among adolescents currently using substances were alcohol and cigarette smoking adolescent social and behavioral characteristics among all the adolescents in this study 135 had a fathermale guardian in their family who was a smoker compared to only 11 of mothersfemale guardians among current alcohol users most of them reported the source of alcohol was stealing and family members in addition adolescents reported having always seen alcohol advertisements and few reported ever riding in a car with a drunk driver on the other hand almost ten percent of adolescents reported having ever had sex of which 585 had two or more sexual partners nearly twothirds reported having 15 close friends and 476 said their parents always understood their problems more than onethird reported always getting social support from their classmates the selfreported prevalence of bullying was 136 furthermore less than a quarter reported having ever engaged in a physical fight substance use by participants socialdemographic and behavioral characteristics there were no significant differences in the proportions of a lifetime and current substance use by adolescent age groups the proportion of lifetime substance use differed significantly by participant characteristics the proportion was higher among males compared to females and adolescents who missed class four days or more compared to those who did not in addition the proportion of lifetime substance use was significantly higher among adolescents who ever had sex ever bullied ever engaged in a physical fight always seen alcohol advertisements and adolescents whose parents rarely understood their problems compared to their counterparts likewise the proportion of current substance use was significantly higher among male adolescents those who missed class four days and more and those who ever had sex which was about four times higher than those who never had sex furthermore the proportion of current substance use was significantly higher among those who had always seen alcohol advertisements ever engaged in a physical fight and whose classmate never showed social support compared to their counterparts adjusted analysis for factors associated with substance use significantly lower odds of lifetime substance use were among female adolescents compared to males those from siha district compared to moshi municipal council and whose classmates always showed social support higher odds of lifetime substance use were among adolescents who have ever had sex ever been bullied ever engaged in a physical fight and always seen alcohol advertisements furthermore lower odds of current substance use were among female adolescents and whose classmates always showed social support the adolescents who ever had sex were bullied engaged in a physical fight always seen alcohol advertisements and whose parentguardians rarely understood their problems had higher odds of current substance use discussion the study aimed to determine the prevalence and factors associated with substance use among secondaryschool adolescents in the kilimanjaro region northern tanzania the lifetime and current prevalence of substance use was 197 and 128 respectively the most prevalent substances used were alcohol and cigarette smoking factors significantly associated with lifetime and current substance use included sex ever having sex being bullied ever in a physical fight seeing alcohol advertisements classmates social support and parentsguardians understanding adolescents problems the lifetime prevalence of substance use among adolescents in this study is higher than 7 from the 2006 tanzanian global schoolbased student health surveys 9 current substance use in this study is also higher than the 2017 gshs which reported specifically alcohol drugs tobacco and cigarette smoking 8 a study in dodoma reported a higher prevalence of substance use specifically alcohol smoking cigarettes and marijuana among adolescents aged 1517 years 25 the current prevalence of substance use in this study is lower than the who global alcohol status report on current use among adolescents aged 1519 years in african regions 7 and a study done among adolescents in ethiopia 26 the possible explanation for the difference may be reporting only one substance in other studies sample size variations and adolescent age compared to the national 2006 and 2015 gshs studies the findings show a higher prevalence possibly because of the small geographical coverage in this study these findings demonstrate a need to strengthen regulatory measures to reduce substance use particularly alcohol and cigarette smoking we found no significant association between adolescent age and substance use however previous studies in zambia 27 and benin 28 in west africa found high substance use practice among adolescents 15 years likewise analysis of gshs data from six asian lowand middleincome countries revealed a higher risk of substance use among older compared to younger adolescents 29 however there are limited studies about the association between adolescent age and substance use in ssa despite the observed differences with other studies interventions should target reducing substance use practice among schoolgoing adolescents because of their ingenuity in trying new things in this study female adolescents had lower odds of using substances than males similar to other studies in morocco zimbabwe and ethiopia 263031 alcohol use is also common among sexually active adolescent males in ssa 32 lower odds of substance use among females may be associated with societal and cultural gender role expectations to act and conduct themselves substance use among females is seen as a shameful inappropriate practice and less sensationseeking behavior than males 263031 adolescents who reported ever having sex were significantly more likely to be lifetime and current substance users likewise in tanzania young people aged 1524 years using alcohol were more likely to engage in risky sexual behaviors 6 a study in ssa associated sexual behaviors with alcohol use 32 the finding is also consistent with studies in iran and bangladesh that associated the experience of sexual activity with substance use 2433 the observed association may be because substances such as alcohol cigarette and illicit drugs affect cognitive processes and decisionmaking thus contributing to a compromised judgment 2433 also sexual activity during these periods can make adolescents vulnerable to developing mental disorders like depression or anxiety which in turn could lead them to use substances 24 health education interventions on the effects and consequences of substance use should be enhanced in secondary schools 8 as reported elsewhere adolescents who have ever been bullied had higher odds of a lifetime and current substance use 34 a possible reason for this is that the victims of bullying are predisposed to use substances as a maladaptive coping strategy 34 in addition a study in thailand found that engaging in a physical fight was associated with alcohol use and misuse where adolescents used substances as a coping mechanism 35 likewise we also found that adolescents who engaged in a physical fight had a higher likelihood of substance use similar to a study done across eight subsaharan countries 36 therefore adolescents need to be educated on the psychological effects that bullying and physical fights can cause explaining how victimization can cause severe depression and anxiety that lead to substance use 37 student support groups or systems for the affected may help the victims cope with the bullying and physical abuse reducing dependence on substance use adolescents who reported always seeing alcohol advertisements were more likely to use substances likewise advertising alcoholic beverages in the mass media promoted abusive alcohol consumption in italy 38 adolescents exposed to alcohol advertising are more likely to start consuming alcohol earlier and drink large amounts 39 a systematic review also demonstrated the relationship between alcohol advertisements and increased consumption among adolescents 40 these findings indicate the need to limit alcohol advertisements in the media or ensure they portray their adverse effects they also suggest prohibiting selling buying and posting substances on school premises especially among schoolgoing and outofschool adolescents 41 this studys findings also show that adolescents whose classmates always showed social support were less likely to use substances these findings are consistent with the study done in bangladesh which reported that the likelihood of substance use increases with a lack of peer support as it exhibits greater antisocial behaviors that can manifest in substance use 24 in malaysia adolescents with inadequate peer support had a higher likelihood of substance use 42 on the contrary a study done in ghana found no association between peer support and substance use 34 the possible reasons could be that the study only assessed two substances ie cannabis and amphetamines compared to over five substances this study examined in addition adolescents whose parents rarely understood their problems were more likely to use substances previous studies demonstrated that parents supervision of adolescents reduces substance use practice 2743 limited parental monitoring involvement and active substance use in the home at the family level may predispose adolescents to use substances 44 therefore lack of social support may expose adolescents to substance use practices as a coping mechanism due to insecurity study strengths and limitations this study used a large sample size of 3224 adolescents from public secondary school schools in four districts of the kilimanjaro region large sample size and wider geographical coverage enhance precision and studys representativeness respectively this study is one of the first in our setting to measure substance uses prevalence and associated factors the study also estimated the burden of a lifetime and current substance use specifically among adolescents aged 1019 years and associated factors which is essential to inform necessary interventions the study had several limitations firstly the study design is crosssectional hence cannot determine the temporal relationship between substance use and the associated factors secondly the study collected data among adolescents attending public secondary schools thus the results may not reflect students in private schools and outofschool adolescents thirdly the questionnaire used for data collection was adopted from the whocdc global student health survey 22 this tool does not capture all the factors associated with substance use these factors include the place of upbringing social sanctions belief systems selfcontrol cultural acceptance of substance use and availability and accessibility of substances particularly drugs and cigarettestobacco products 242645 the tool does not also capture the consequences of substance use among schoolgoing adolescents lastly there was also a possibility of recall and socialdesirability bias where adolescents might have forgotten or answered what they thought was socially desirable such bias may either over or underestimate the prevalence of substance use conclusion and recommendations the study reflects the high prevalence of substance use among adolescents in the kilimanjaro region alcohol and cigarette are the most prevalent substances used the factors significantly associated with substance use were sex ever having sex being bullied ever in a physical fight seeing alcohol advertisements classmates social support and parents guardians understanding adolescents problems the study recommends that students leadership with support from the teachers create support groups or clubs that may help adolescents share alternative healthy ways of copingdealing with stress anxiety and depression caused by bullying which leads them to rely on substance use the government should adopt regulatory measures to limit the number of alcohol advertisements the media portrays monitoring adolescents prohibition of selling and buying any substance such as alcohol and tobacco products is crucial in or near the school premises data processing and analysis data were cleaned and analyzed using spss software version 20 descriptive statistics for substance use characteristics were summarized using frequencies and proportions for categorical variables continuous variables were summarized using mean and standard deviation the chisquare test determined the association between participant characteristics with lifetime and current substance use binary and multivariable logistic regression analysis estimated odds ratios and 95 confidence intervals for determinants of a lifetime and current substance use a pvalue of 005 was considered statistically significant in crude and adjusted analyses ethical consideration the kilimanjaro christian medical university college research and ethics review committee approved the parent study all people aged 18 years and above provided data curation

substance use among schoolgoing adolescents increases the risk of developing mental disorders addiction and substance use disorders these may lead to poor academic performance and reduced productivity which affects adolescent lives the study aimed to determine the prevalence of substance use and associated factors among secondary school adolescents in the kilimanjaro region northern tanzaniathe study used secondary data from a crosssectional survey of adolescents aged 1019 years from public secondary schools in the kilimanjaro region northern tanzania substance use was measured using the global school health survey gshs questionnaire categorical variables were summarized using frequencies and percentages while numerical variables used mean and standard deviation multivariable logistic regression models were used to obtain odds ratios or and 95 confidence intervals ci to determine risk factors associated with lifetime and current within the past 30 days preceding the survey substance usethe lifetime and current prevalence of substance use among 3224 adolescents was 197 and 128 respectively while alcohol and cigarettes were commonly used female adolescents had lower odds of current substance use or 063 95 ci 050080 higher odds of current substance use were among adolescents who have ever had sex or 431 95 ci 325571 ever engaged in a physical fight or 219 95 ci 173278 ever been bullied or 155 95 ci 116205 always seen alcohol advertisements or 187 95 ci 137253 and adolescents whose parentguardians rarely understood their

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introduction womens education refers to the providing of all educational facilities and opportunities to women our constitution places a high value on gender equality in terms of status and opportunities the state may not discriminate against any citizen based on religion caste gender or place of birth as a result women receive equal educational chances and facilities as males regardless of caste religion or region drs radhakrishnan states there cannot be educated people without educated women if general education has to be limited to mere men or women the opportunity should be given to women for then it would most surely be passed on to the next generation realising the necessity and importance of womens education the national policy on education states the education of women should receive emphasis not only on grounds of social justice but also because it accelerates social transformation throughout most of human history the status of girls has been poor and submissive from ancient times to the current era womens rights to dignity and independence have been violated girls low involvement in school may not be linked to their low participation in economic activities but it is worth noting that their contribution to the indian economy is lesser according to the 2001 indian census muslims account for 134 of the indian population the literacy rate among muslims is 591 which is lower than the national literacy rate however the literacy rate among muslim girls is 501 percent while males have a rate of 676 percent the literacy rate among muslim girls in rural areas is 427 lower than in urban areas female education is critical for the development of individuality it is also a tool for developing socially desirable abilities habits and attitudes towards common citizenship in practically all levels of education in india girls continue to be marginalised in terms of enrolment rates in recent years the marginalisation of girls and the issue of educational inequality have become serious issues in india muslim girls are similarly marginalised in the educational arena and multiple conversations have taken place to identify and study various causes that contribute to their marginalisation in education ranging from the political level to general difficulties review of related literature usha nayar has studied muslim women and girls who fall short of their male counterparts with 31 of their population living in poverty muslims had the greatest rate of poverty muslim girls had an average literacy rate of 501 compared to a communitywide average of 537 in urban regions the gender gap in literacy rates was 131 compared to 967 in rural ones comparing muslims to the national average of 67 just 36 have degrees in 2001 39 years were spent in school by men aged 7 to 16 years muslim men had an average age of 326 and muslim women had an average age of 27 the studys conclusions showed that the marginalisation of muslims in education supported womens sex inequality muslim women girls education was a case study from hyderabad journal of indian education may 2006 the present paper was as out the educational status of muslim women and the attitude of parents towards education of their girls in slums of hyderabad according to the report girls drop out at a lesser rate than males do in primary school but their numbers rise as they progress through the grades despite the fact that basic education in public schools is free many families prefer to send their children to madrasas these madrasas need to be updated and furnished to be able to offer formal education in addition to religious instruction wasey a in an article realising the importance of girl education emphasised the efforts done for muslim womens education by sir syed ahmad khan sheikh abdullah and nawab mohsinul mulk he came to the conclusion that up to 85 of lower caste muslims were illiterate after evaluating the current situation of muslim womens education the primary reason muslim parents did not educate their children was their utter financial incapacity marriage and the negative effects of dowry were the other factors preventing muslim girls from pursuing higher education research gap pathan has done a study on educational backwardness of the muslim women containing economic social religious and political factors and other causes responsible for the educational backwardness of the muslim women in solhapur district sabiha hussain in north bihar has studied economic and political factors drooping out for various factors manju narula objectives of the study  to find out the factors affecting higher secondary education of muslim girls  to study the awareness of muslim girls towards higher secondary education  to find out the attitude of muslim girls towards higher secondary education  to understand the current state of higher secondary education in relation to the fundamental needs of girls delimitation of the study because of short time span present study was delimited to 1 the study was delimited to beldanga1 block of higher secondary schools muslim girl students 2 only 4 schools were selected for purpose of data collection in beldanga1 block of murshidabad important terms defined educational marginalization it is a process where someone is pushed to the edge of a group getting minor importance this is predominantly a social phenomenon by which a minority or subgroup is excluded and their needs or desires are ignored the prevailing circumstances and social forces of the society which are historically and traditionally make the muslim girls backward observed studies and researches on girl education so the first and allembracing need of girls education in muslim society today is that it should be realistic related to life in this study the word marginalization is referred to describe the educational backwardness of muslim girl students in higher secondary education women education women education is one of the most important objects for the development of the country its because an educated woman can help to enhance their family society and country as well they can look after their children duly can help their hubby to live their life happily and successfully methodology of the study the descriptive survey method was chosen in light of the demand and the nature of the investigation the current research was a descriptive survey  population all higher secondary muslim girls in murshidabad district in west bengal  sample 100 higher secondary muslim girls from beldanga1 block from the district of murshidabad  sampling procedure sample was selected through purposive sampling technique as because there is less time to cover up all samples tools used there are three tools used by the researcher for fulfilment objectives in this study and all are three tools constructed by the researcher through proper standardized manner data analysis and interpretation objective 1 to find out the factors affecting higher secondary education of muslim girls after focus group discussion the researcher found the following factors for the marginalization of the muslim girl students in higher secondary education such as major factors 1 negative attitude of parents negative parental attitude towards educating daughter can also be a barrier for a girls education according to many parents educating sons are an investment because they are responsible for caring their aging parents the education of daughters as a waste of money because daughter will eventually live with their husbands families and the parent will not be benefited directly from their education or daughter with higher levels of education will likely have higher dowry express conservatism most of the people of muslim society feel that educated girls become morally deprived the purdah systems among muslim society for girls have been created great hindrances in the expansion of girls education the traditional prejudices still operate as sign of backwardness in rural areas to some extent in fact the lower and poor section of the society falls as an easy prey to these superstitions and traditional prejudices poverty the poor economic condition of parents is the greatest obstacle in the way of the development of girls education in backward district like murshidabad education has become costly affair hence it is not an easy task for poor parents to make suitable arrangements for the education of their daughters early marriage the early marriages among muslim girls were creating barriers in the expansion of girls education murshidabad is the one of the backward districts in west bengal parents think that the only objective of their life is to marry of their daughters they do not even consider the fact that education is indispensable to lead an independent life objective 2 to find out the awareness of muslim girls towards higher secondary education analysis of dimensions 1 awareness of muslim girls related to socioeconomic factors affecting higher secondary education 1 parental awareness about 90 of girls think that parental awareness is most important for their girls education because if the parents were aware about their girls therefore their girls would be educated but near about 10 of girls did not think like that according to them their own awareness is most important for their educational development family encouragement near about 54 of girls accepted that their family encourage for their education because their family know the girls education is most important for society but round about 46 did not accept because their parents were illiterate who did not encourage their girls for getting education poor economic condition every girl in the sample believed that poor economic condition is the main reason for backwardness of muslim girls in getting higher secondary education in murshidabad district many people have to go outside for earning wages for their livelihood 4 social superstition round about 79 of girls described that social superstitions are one of the main reason for backwardness in higher secondary education because of purdah system and every decision depends upon their own will where girls need to be covered in hizab but approximately 21 of girls did not accept it because they think social superstition is not a barrier in getting education clear concept about 36 of girls express their views in favour of clear concept about higher secondary education because they know all things related about higher secondary education but near about 64 of the girls accepted they do not have clear concept of higher secondary education because of they had no sufficient knowledge about higher secondary education backwardness in higher secondary education approximately 82 of girls agreed that muslim girls are backward in higher secondary education because they think muslim girls are neglected from society and their poor economic condition but about 18 of girls not agreed that muslim girls are backward in getting higher secondary education because they think muslim were not backward in any section stream selection near about 41 of girls express their views in favour of what type stream having in higher secondary education because of they know how many streams have higher secondary education but round about 59 of girls accepted they did not know what type stream having in higher secondary education because they had no information what type stream having in higher secondary education rights of girls after getting higher secondary education about 72 of girls were accepted that after getting higher secondary education they are more conscious about their rights because of only education provide information about many types of rights but approximately 28 of the girls express that higher secondary education make no effect over conscious about their rights because of they think only higher secondary education is not enough for conscious about their rights vocational education near about 28 girls express their views in favour of aware of getting vocational education because of they know after getting vocational education they will be selfindependent but about 72 of girls accepted they did not aware of getting vocational education because of they have no sufficient information about vocational education 6 selfdependent round about 58 of girls agreed that higher secondary education get selfdependent because they think after competition of higher secondary education they get a part time job but about 42 girls did not agreed that because they think only higher secondary education not provide any kind of job 1 scholarship near about 61 of girls were aware about availing scholarship at higher secondary level because they know how many scholarship available in higher secondary education about 39 of girls were did not aware about availing scholarship at higher secondary because their lack of awareness to know how many scholarship available in higher secondary education 2 computer only 20 of girls have opportunity to use computer in school because of their school had computer facility but 80 of girls do not have such facility because of their school had no computer facility family pressure near about 14 of girls express their views in favour of they have admitted in higher secondary level because of their family pressure they do not prefer any type of traditional education but approximately 86 of girls did not accept that they think only education change their life 2 support from school teachers about 34 of girls express their view in favour of their school teacher has encourage for getting higher secondary education at secondary level because this percentage of girls had great encouragement from their teacher but round about 66 of girls did not accept that thats mean no cooperation from their school for admitted in higher secondary level misinterpretation of religion approximately 22 of girls says that religion is the barrier to getting education because of in murshidabad district many moulobis misguide them they told only religious education fulfil your life about 78 girls says that religion is not the barrier to getting education because of their society is conscious about girls education 4 negative behaviours from society members near about 33 of girl students acknowledge they have experience negative behaviour from society members because of their living society is not accept in kind of modern education but about 67 of girl students did not acknowledge that they told their society encourage for their education analysis of dimensions 2 attitude of muslim girls related to higher secondary education 1 satisfaction in higher secondary education about 63 of girls satisfied of their stream at higher secondary level because they admitted in happily but approximately 37 0f girls did not satisfied of their stream at higher secondary level because of they did not happy with their stream this percentage of girls had no opportunity to select other stream burdening getting higher secondary education near about 8 of girls student think that higher secondary education is burden because they are little more intelligent but round about 92 of girls did not think that because they are capable for higher secondary level education interested in getting higher secondary education approximately 86 of girls interested to getting higher secondary level education because they think education most important for all muslim girls but about 14 of girls student not interested to getting higher secondary level education because they interested in vocational training completion of higher secondary education near about 98 of girls think that they should finish at least higher secondary education because they know for changing society girls education is must but about 2 of girls did not accepted that because of they should complete graduation level need of getting opportunity in higher secondary education 100 of girls want much opportunity to carry out higher secondary education for muslim girl because many muslim families are belongs to poor economic conditions 6 vocational education as a substitute 11 of girls interested in vocational education as a substitute of higher secondary education because they were accept that after getting vocational education they will must a job or work but 89 of girls are not interested in vocational education as a substitute of higher secondary education because of this percentage of girls realise that they had need to higher secondary education to change the negative views of conservative society home science as a subject in higher secondary education 21 of girls were agree with the home science subject as a part of higher secondary education curriculum because of good arrangement of their living home but 79 of girls disagree with that because they acknowledge that no need to home science subject as a part of higher secondary education curriculum in the field of study the observer reached 4 schools is that conclusion that several necessities regarding the present situation of the secondary education girls have manifested can be underlined below these is as follows 1 it is found that among 4 higher secondary schools 3 schools were nearer to the location of muslim girls and 1 is far away from the area of living 2 it is observed that 2 schools had security guard for purpose of students security and another 2 school had not security guard 3 the observation was done in 4 schools by the researcher out of which 1 had the facility of separate common room where as others had no separate common room facility for girls 4 among the 4 observed schools only 1 school had conducive environment educative students and the other 3 had lack of these facilities 5 there was no counselling officer for the students who are suffered depressed mentally emotionally is any observed schools in beldanga1 block of murshidabad 6 only 1 school had proper sanitation facilities and other 3 have poor conditions which are man at work and the toilets keeps wash once in two weeks 7 the due observation shows that among these 4 schools 1 school had the facility of providing vocational training with the regular course and one school provide selfdefence course for the girl students left 2 school had no these kind of facilities 8 it is observed that only 1 school had computer facility but without internet and another 3 schools had not computer facility 9 all the observed schools organise cultural programmes rallies educational drama and other amusing activities in the school premises 10 in every observed school the schools conduct a meeting with the guardians regarding the problems of childs their needs and educational practices each year in the month of june 11 among the 4 observed schools 3 schools follows awareness and news uptodate regarding scholarship fellowship for the betterment of the girl students and one school have not that kind of facilities 12 among the 4 observed schools only 1 school provides separate subject for the girl students like home science home nursing but another 3 school did not provide any separate subjects to the girl students 13 among the 4 observed schools 2 schools had a appointment of special women for caring girl students but rest of 2 school did not had these opportunities conclusion researcher attempts to find out why muslim girls are marginalized in higher secondary education awareness and attitude of muslim girls related to higher secondary education researcher found that several major and minor factors affecting in higher secondary education many girls had no clear concept and many girls did not know how many streams have in higher secondary education because of their lack of awareness it is found that there is very low enrolment ratio of girls education most of the girls are not aware about scholarship facilities which are given by ngos and government in this study researcher found that poor economic condition and early marriage of girls is the main barrier to getting girls education thus government and society should take proper plans and policies to encourage the girls education it is concluded that this study will helpful to increase the awareness about girls education

education is the backbone of the nation just as womens education is the main tool for the development of society indian society is a traditionally and culturally diverse society this society is inhabited by people of different classes different castes regions and different religions muslims are the largest minority group in india but educationally they are one of the most backward people in the country muslim women are far behind the boys and girls of other communities in terms of education money and social status education is considered to be the only process that guides the social economic cultural and political development of the individual education is the only tool for change and development of the society the main purpose of this research paper is to look at the reasons behind the backwardness of muslim women in higher education the main reasons for the backwardness of muslim women in education are large families ignorance about the importance of education lack of connection between madrasah education and modern education poverty negative attitude towards girls education lack of security for girls

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introduction in recent years with the gradual enhancement of peoples awareness of gender equality global attention to women is also increasing governments or social organizations in various countries have also launched many solutions to social problems related to women with the development of new media media platforms pay more and more attention to social issues such as gender equality and womens rights among them womens fertility has always been a topic of concern the emphasis on womens fertility is one of the manifestations of respecting the independence of womens reproductive rights it involves not only the reproduction of human beings but also the physical and mental health of women themselves at present there are relatively few research academic papers on the impact of media on womens reproductive rights in china however in the academic circles of western countries such as europe and the united states there are research papers on this aspect although most of them revolve around the abortion issue but in essence abortion is a specific expression of womens reproductive rights women around the world have used a variety of channels to protest against issues such as the ban on abortion in order to fight for their own interests among them the media coverage of womens reproductive rights is mostly stigmatized and politicized researchers like carrie purcell shona hilton and lisa mcdaid described the stigma of abortion in a paper published by the nih among the issues reflected in the majority of the articles are that women seeking abortion is an inactive and illegal choice media coverage of these negative views stigmatizes women who want to have abortions which is tantamount to challenging womens reproductive decisions 1 in addition zoe larkin published an article on abortion media coverage in 2020 through a new report by naral prochoice america and global strategy group the author found that most abortion coverage in mainstream media is politicized and problematic 2 therefore the reproductive rights of fallen women have been greatly affected and the media plays a very important role in it however this paper mainly studies the influence of media based on chinas family planning on chinese womens reproductive rights the research theme of this paper is based on chinas family planning trying to explore the law and degree of medias influence on chinese womens reproductive rights and put forward ideas and suggestions this paper makes research by enumerating examples presenting data and analyzing and comparing it is divided into four parts the first part introduces the background of womens reproductive rights and then illustrates the existing methods and approaches to protect womens reproductive rights the second part mainly analyzes the negative and positive impacts on womens reproductive rights under traditional media and new media the third part mainly analyzes the positive influence and role of the development and progress of media on womens reproductive rights under the background of chinas family planning the fourth part is the conclusion putting forward how the media should do to realize the protection of womens reproductive rights can play an obvious role the research of this paper aims to explore the changes in the influence of chinese media on womens reproductive rights and how many changes there are by studying this problem the national government and social organizations can pay more attention to female reproductive rights at the same time the whole society especially the media and women should be encouraged to make full use of the comprehensive impact of media communication in the digital era on womens reproductive rights so as to realize the true protection of womens reproductive rights reproductive rights of women introduction to the background of female reproductive rights in 2014 the united nations published a manual entitled reproductive rights are human rights which mentioned that reproductive rights are actually human rights and are not new rights reproductive rights mainly refer to the various civil political economic social and cultural rights of individuals and couples in their sexual and reproductive life 3 a series of measures to protect womens reproductive rights summarized by the united nations have not attracted more attention and publicity reports from the media around the world in many regions or media reports social problems related to discrimination against women are still often found from the definition of reproductive rights given by the united nations it is not difficult to see that the issue of womens reproductive rights can be related to many social problems that women encounterthis includes both married and unmarried women methods and approaches to protect womens reproductive rights in addition to the committee on the rights of the child the committee on human rights and the committee on economic social and cultural rights statements have been made on various fronts countries in america africa and europe have also made relevant decisions on reproductive rights to protect womens right to give birth freely the new zealand government has stipulated that employers must reserve their jobs for those who take maternity leave after maternity leave unless the company closes down or shuts down employers must unconditionally accept the mothers to return to their original jobs 4 these decisions show that womens rights have been taken seriously although public awareness of womens reproductive rights is not strong enough the united nations is trying to implement the treaty every year countries around the world are also actively cooperating 3 despite this people around the world still face the problem of not being able to guarantee their reproductive rights it is the power of the media to make these details visible to the public no matter which era the media is an important medium to spread information and it can still have a huge impact on womens interests making good use of the communication efficiency of the media platform is the most effective way to attract peoples attention factors affecting female reproductive rights in media communication the concept and difference of traditional media and new media the traditional medias way of obtaining information is more reflected offline where it stresses uniqueness whether in newspapers periodicals or radio traditional media pay more attention to the unique such as some exclusive reports moreover traditional media report more based on the overall direction of government development and the content needed by social groups with the continuous development of social science and technology and the comprehensive popularization of the internet the emergence of new media has led to the development of media platforms and given more people the opportunity to show themselves for example anyone can post a video on tik tok and start a live stream they can even write their own scripts be actors and so on compared with traditional media new media pursue more effectiveness through the connection between platforms new media rely more on headlines to attract people it needs to quickly convey useful information to people in the new media environment people can not only listen to information but also communicate and express their own opinions and ideas social media offers the possibility of massive access to information as well as a platform for online communication and interaction about anything for the majority of women who have grown up in an environment of the continuous development of the internet social media will have a significant impact on their internal individual values and behaviors the emergence of new media is undoubtedly an important opportunity for women to safeguard their reproductive rights analysis of gender inequality in media communication at present there is a serious problem of gender stereotyping in most of the media we have seen and even a problem of female media workers being targeted according to ims only 24 percent of the people who heard read or saw in newspapers television and radio news were women fortysix percent of news reports even reinforced stereotypes while only four percent of media outlets chose to confront gender stereotypes 5 in addition men still generate 621 percent of all print news at the largest circulation of newspapers and wire services according to a 2015 report by the womens media center according to mics maledominated media coverage of reproductive rights by julie zillinger this dominance and its subsequent impact on coverage can lead to a media landscape that does not reflect womens actual experiences which in turn can have negative consequences research has repeatedly shown that media representation is particularly important to women and can affect young womens selfconcept in a very real way the impact of media on womens reproductive rights chinas family planning policy on womens reproductive rights in the early days after the founding of new china chinese people had a high desire to have children and the chinese government also adopted a policy to encourage childbearing at the very beginning but the first census shows that chinas population is growing too fast so the central according to the data from the national bureau of statistics it can be seen that the 1970s especially the late 1970s was a period of fundamental transformation in chinas population development the pressure brought by the rapid population growth since the founding of new china has made people realize that population control is imminent the chinese government began to carry out family planning and successively formulated and improved a clear family planning policy bringing the momentum of a high birth rate and high growth of the population under rapid control the population has entered a period of planned and controllable growth following unplanned and spontaneous high growth during this period the birth rate and natural growth rate declined rapidly from 307‰ and 234‰ in 1971 to 182‰ and 119‰ in 1980 respectively 6 but since 1980 when one child per couple became mandatory there has been a retaliatory increase in the birth rate of the total population except for a slight decrease in 1980 and it has never returned to the low level of the 1970s at the time of chinas liberation many married women were expected to have more children because of the deeprooted cultural influence of the feudal period and there was even a son preference in china at that time so women were already in a situation where their reproductive rights were violated on the basis of absorbing enough public opinion the chinese government launched the late birth plan which was the most suitable policy for chinese women at that time to truly protect equality women did not have too much power and channels to protect their own rights and interests at the time when chinese media was not developed enough which to a large extent protected the reproductive rights of most women especially in feudal china the marriageable age for men and women was 14 and 16 respectively after liberation the chinese governments late birth proposal undoubtedly greatly protected women the influence of media communication on female reproductive rights according to a report on january 1 2013 blogs in china daily published an article family planning why negative coverage increased from 14 solstice december 30 2012 successively has the southern daily south metropolis daily the popular daily lifethe china youth daily a total of seven illegal behavior of negative reports about family planning department 7 in the 1980s and 1990s chinese media reports and articles about family planning were basically onesided propaganda that family planning benefits the country and the people and there were almost no negative reports about family planning and family planning departments so has there been an increase in family planning violations in recent years in fact compared with the 1980s and 1990s there have been fewer not more illegal activities by family planning authorities in recent years why has the illegal behavior of the family planning department decreased and the negative coverage of family planning increased at that time family planning was a basic national policy in china and long articles or reports in newspapers radio television and other media promoted this policy but no media focused on the issue of gender equality or dared to challenge this topic then in the process of policy implementation as the implementation of the policy of the relevant departments and local governments or the grassroots didnt understand the intentions of the central government the first time have some deviation because even some incorrect way of publicity the media in some places for the sake of socalled achievement make some let people resistance behavior these practices and behaviors ignore womens dominant position in the implementation of the family planning policy in recent years with the rapid development of chinas science and technology economy the internet has been constantly popularized and the scale of chinese netizen has been expanding internet users the proportion of men and women is 515485 8 according to the data comparison the gender ratio of chinese netizen has been developing in the direction of continuous optimization from 2013 to 2021 the proportion of female netizen in china increased significantly online media reports and discussions on womens reproductive rights and womens rights are also increasing and some even touch on sensitive topics about womens reproductive rights in todays society as reported by sina news on march 02 2022 huang xihua a deputy to the national peoples congress suggested that single womens reproductive rights and the equal rights of children born out of wedlock should be guaranteed the national health commission and womens federations should introduce policies to allow single women to enjoy the same reproductive rights and benefits as married women 9 with the increasing proportion of women using the internet women have more opportunities to learn about relevant reports and information through modern media and thus have more opportunities to interact and speak out through media platforms which promotes womens rights to receive more attention and attention from the whole society discussion in such an environment the only contribution the media can make to womens reproductive rights seems to be the announcement of specific contributions made by the government or social organizations for womens reproductive rights or the platform provided by social software for everyone to communicate only mutual communication and ideological collision can cause the topic to get more peoples attention and attention although todays media can give a voice to every member of the public at present most media still only exists in a form of equality internet social networking platforms are open to everyone but there is still a big gap between women and men in the use of internet digital technology in developing countries alone women account for 41 percent of internet penetration while men account for 59 percent according to the united nations at present womens reproductive rights and even other aspects of womens rights are still affected by some factors and cannot be guaranteed for example some work units take into account that women need to be pregnant and give birth and stipulate certain additional conditions when recruiting women there are also terms such as female driver which reflect female stereotypes in media reports these discriminatory restrictions which pervade recruitment and even employment in almost every industry are absurd and cruel 10 conclusion media can play an obvious role in safeguarding womens reproductive rights it can be seen that the precondition for the media to play a role is that the media can break gender stereotypes not attract heat in traditional forms and challenge problems and concepts brought by traditional society therefore as a medium it is necessary to spread correct values in the process of information dissemination guide public opinion appropriately and promote peoples understanding and recognition of gender equality secondly we should develop female media and construct the female public sphere of course the purpose of establishing female public sphere is not to exclude men but to express female voices obtain equal rights of discourse and safeguard female interests thirdly the media should set an example by using advanced culture to educate women improve womens quality increase the number of women in employment and promote gender equality in an effort to draw the attention of governments and social organizations around the globe to womens reproductive rights this paper makes suggestions and attempts to analyse the impact of the media on womens reproductive rights and its causes from the perspective of chinas family planning policy given the short time frame data collection needs to be enhanced further and a thorough examination and knowledge of womens reproductive rights in other nations particularly in developing countries is still required the author will keep gathering pertinent data and further the study of womens reproductive rights in developed and developing nations in europe and the united states

the topics related to chinas family planning policy have always attracted attention from the media the internet and academic research circles for all the attention some people have proposed research and discussion on womens reproductive rights based on the history of chinas family planning policy this paper will focus on analyzing its role and influence in the communication of female fertility policy and social phenomena from the perspective of the media according to the research media communication has a profound and huge impact on womens reproductive rights on the one hand with the development of new media platforms media platforms pay more and more attention to social issues such as gender equality and the rights of women on the other hand contact and interaction with media content will not only directly affect womens conception of fertility but also indirectly affect others by influencing women

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background intravaginal practices refer to methods used by women frequently to manage vaginal hygiene and address perceived disruptions to vaginal health 12 ivps consist of intravaginal washing or douching with liquids such as water water with soap or household cleaning products wiping inside the vagina with cloth or tissue and applying or inserting substances with the intent to warm dry or tighten the vagina 3 4 5 evidence suggests a wide range of ivps among the general public across the globe 6 however the prevalence of ivps is higher among female entertainment workers women who work at entertainment venues where they sing dance flirt give massages and sometimes engage in transactional sex 13 7 8 9 women use ivps for perceived hygienic and healthpromoting reasons despite ivps having been linked to adverse health effects 1 ivps may contribute to disease via several mechanisms they may disrupt the genital mucosa and cause vaginal and cervical inflammation they may disrupt normal vaginal flora and allow the growth of pathogens or they may provide a vehicle for the transport of a pathogen allowing lower genital tract infections to spread beyond the cervix and into the uterus fallopian tubes or abdominal cavity 1 10 11 12 as a result ivps can increase the risk of contracting sexually transmitted infections and other vaginal infections which may increase the risk of human immunodeficiency virus transmission 1412 in addition ivps have been implicated in numerous adverse reproductive health outcomes including increased risk of pelvic inflammatory disease reduced fertility ectopic pregnancy preterm delivery low birth weight and cervical carcinoma 13 14 15 studies in asia africa and the americas reveal that utilization of ivps is widely prevalent within the sex and entertainment industry these practices are utilized by anywhere from 40 to sometimes nearly 100 of fews as well as sex workers depending on the region 3 4 5 6 7 8 9 16 17 18 in cambodia studies have shown that ivps are used by 77 of females in the general population and up to 91 of fews 319 one study in cambodia showed that fews do not only more frequently practice ivps but they use ivps that are more diverse in type and method 16 additionally as fews are more likely to be exposed to stis and to develop vaginal infections than the general public they are exceedingly more susceptible to hiv infection and adverse reproductive health outcomes 3 fews stated several motivations for using ivps the motivations include wanting to prevent stis promoting cleanlinessavoiding odors relievingtreating symptoms of illness promoting general health and wellbeing fresheningtightening their vagina to increase sexual pleasure for their clients and preventing unwanted pregnancies 231718 20 21 22 23 24 some studies found that fews perceive ivps as their duty as women or as sex workers to be presentable for their clients 324 most women reported utilizing ivps once they entered into sex work or within one or two years of beginning sex work fews reported performing ivps before and after having sex with clients 3 frequencies of ivps among fews can be from one to 28 times per week 31820 fews have reported learning about ivps from their mothers 7 friends and healthcare providers 3 beyond selfcleaning practices fews in cambodia have reported getting professional ivp services offered in clinics or salons 320 this qualitative study explores the social professional and peer context surrounding ivps the experiences of selfcleaning or receiving services from a health professional and the perceived effects of ivps among fews in cambodia methods this analysis was part of the formative study for the development of the mobile link a randomized controlled trial aiming to improve sexual and reproductive health of fews in cambodia the trial aims to engage fews through messages on their mobile phones and link them to the existing highquality prevention care and treatment services in the country we have published the details of the mobile link projects protocol elsewhere 25 in short the research team gathered information on knowledge attitudes and practices related to sexual and reproductive health among fews in the four provinces with the highest hiv burden in cambodia to inform the mobile link message creation and program implementation 26 for this study we examined transcripts of the focus group discussions and indepth interviews where women discussed ivps researchers at a cambodian health organization khana who have been working with fews for over 10 years led this project fgd and idi guides were codeveloped by the research team with the program team and peer outreach workers questions were openended and the topics included in the guides covered a wide range of sexual and reproductive health topics including hiv genderbased violence and substance use we conducted a twoday training for the two female data collectors a peer data collector and a community lay health worker in each province the training provided guidance on the objectives of the overall project including how to use the fgd and idi guide tools and basics of conducting fgds and idis especially with vulnerable populations the guides were also piloted in each province and revised based on local feedback we trained the moderators to follow the guides and gave them the authority to use facilitation techniques to encourage participant interaction even if it went offtopic field notes were taken and used to incorporate changes into the final versions of the tool following the project team debriefing after each pilot fgd sampling and site selection in each city we used a twostage cluster design to identify entertainment venues first we randomly selected a venue from a list of entertainment venues in the province by venue type then outreach workers recruited fews to participate by approaching them at their place of work before work hours eligibility requirements for participation were the following working in entertainment in cambodia between the ages of 18 and 30 currently sexually active in possession of a mobile phone and can send receiverespond to a text message and able to give their informed consent once a participant agreed to participate her contact information was collected and she was given the time and place to meet for the focus group or interview data collection process focus groups focus group data collection occurred in four provinces over three weeks with concurrent data transcription and translation the project coordinator oversaw the data collection activities before arrival at the organizations community center where the data collection took place the data collector worked with the peer data collector to organize logistics the community health worker contacted all recruited participants to ensure they would arrive on the day of the data collection upon arrival participants were permitted to view and casually discuss topic listed on cards around the room hung by the community health worker the data collector read the informed consent to the participants asked for their verbal consent signed as witnesses and gave a copy of the consent form no one else was present during the data collection aside from the two data collectors and the participants each fgd lasted around 90 min and covered various topics the topics included stis hiv modern contraception gynecological health condom use cancer pregnancy genderbased violence and substance use within each topical area questions explored participants understanding of the topic area known myths misconceptions practices related to the topic and how the health information and linkages could be used to improve outcomes related to that issue women were encouraged to share specific experiences such as stories from their own lives to generate conversation details about the methodology of the focus groups including the focus group guide have been previously published 27 field notes were taken during the focus group discussions to capture nonverbal cues as well as track themes and patterns in responses revision workshops were conducted where researchers provided a summary of the data collected during the fgds to the participants in order to get their feedback and confirmation of results followup interviews after the initial fgd transcripts were analyzed the research team decided to go back to the study population to learn more about intravaginal practices as this was identified during the fgds as a top health issue the data collection team then conducted semistructured idis with participants who were available at randomly selected venues in phnom penh and siem reap during prework hours an interview guide was developed and pilot tested based on the ivp themes from the focus groups and workshops questions were asked about where participants have received advice about cleaning motivations to clean selfcleaning practices professional cleaning services and frequency of cleaning the full interview guide developed for the followup interviews is provided as additional file 1 data collectors continued to interview participants until they felt they had reached data saturation all fgd workshop and ids were audio recorded and audio files were uploaded into a locked dropbox managed by the project coordinator transcribers accessed the audio files transcribed the data into khmer and uploaded khmer transcripts into a second dropbox folder translators then accessed the khmer transcripts to translate into english and upload the english file into the final dropbox folder a total of 27 fgd with 8 participants in each group and 16 idi transcripts formed the data set for this project for a total of 232 participants approximately 10 of those approached declined to participate in the study due to being busy at work and not having enough time to join transcription and translation all audio files were transferred into a passwordprotected digital folder by the project coordinator transcribers were granted access to the audio files where they transcribed the data into khmer language then the khmer transcripts were uploaded into a second digital folder a team of translators read the khmer transcripts and translated them into english the final english transcripts were read by the project coordinator for clarity and any clarity issues were dealt with by referring to the original audio file data analyses the data from the transcripts were analyzed using dedoose version 80 35 a web application for managing analyzing and presenting qualitative and mixed method research data the analysis followed thematic analysis procedures and two researchers developed codes inductively based on participant comments which addressed the research questions 28 secondly we used thematic coding to identify themes that illuminated the influences experiences and cleaning processes from the participants perspectives the first two authors developed the codebook iteratively based on the first round of coding of a sample of fgds and idis and then coded the rest of the transcripts then the codebook was applied to the 16 followup idis once those were completed the codebook was refined and amended to encompass any new information gleaned from the followup interviews finally a conceptual model was developed based on the codebook which depicts the authors impression of how the codes all relate to each other ethical consideration this study was approved by the national ethics committee for health research within the ministry of health in cambodia and the touro college institutional review board all members of our research team have undergone a research ethics training on the protection of human research participants through the national institute of health online training program all fgd and idi participants went through an informed consent process where they were told the study purpose the risks and benefits to their participation and the voluntary nature of their participation the data collector read the informed consent to the participants asked for their verbal consent signed as witnesses and gave a copy of the consent form each participant was given copies of the consent form translated into cambodia language the data collectors ensured that the fgd and idi spaces were private and confidential this study required some participants to discuss sensitive topics in a group setting participants were informed of the special issues of confidentiality that come with the focus group study design in addition participants were offered escorted referrals to counselors and health services including to a local womens center results figure 1 depicts the relationships between the main themes and subthemes stigma is an overarching theme that impacts messages about cleaning the cleaning process and the impact of cleaning stigma in intravaginal practices stigma was a persistent thread throughout this analysis experiences of enacted stigma as well as internalized stigma permeated conversations about intravaginal practices experiences of enacted stigma were linked to cleaning such as being told that fews are dirty by health providers internalized stigma was also apparent when women talked about the causes of gynecological issues among fews women talked about their own colleagues ignorance laziness dirtiness and willful refusal to practice ivp as primary causes rather than their limited health care access socioeconomic status or work environments the doctor from the clinic and his colleague said that we have dirty stinky vaginas and we dont respondent 1 some fews just dont know how to protect and clean respondent 2 sometimes after they have sex with clients they dont clean their vagina and keep it all day messages about ivps women described a landscape of many sources of varying information about whether and how to wash the vagina and the potential benefits and consequences of washing the information was often contradictory elders family peers doctors were all mentioned as sources of information and advices about cleaning from family and community several women shared stories of learning about washing from members of their community information that was passed down to them about how to care for their bodies moderator how long have you known about that salt and lemon technique r a long time ago elder people talk about it the elder khmer people told me from other fews fews spoke about sharing cleaning practices almost as if they were passing down such knowledge is a part of their professional duties my sister always wants the doctor to check on her and do the cleaning she said fews are supposed to do the health checkups of the uterus every six months depending on our availability therefore i follow her routine as well then we explain it to the newcomers since they dont know from health providers women shared practices and advice received from health providers about cleaning women reported that doctors both encouraged and discouraged cleaning practices women stated that doctors suggested that they clean to maintain hygiene without being detailed about how or in some cases encouraged them to seek professional services for cleaning in the excerpts below women shared information they received from doctors discouraging them from washing i was told that too much cleansing can cause leucorrhea so the doctor told us to use normal water instead since cleansing gel may cause irritation if not properly cleaned in contrast other women reported receiving advice about how important selfcleaning is to maintaining hygiene the doctor told me that as a woman i have to know how to keep proper hygiene and protect myself at home so i clean myself frequently while the above example shows how some doctors might express support for some forms of athome cleaning the example below underscores the lack of clarity about what washing entails m and where do you get that cleaning technique from r i went to the hospital and the doctor told me to clean and protect myself from infection something like that the excerpts above allude to advice about athome cleaning as a part of maintaining hygiene however in the excerpts below women discussed how doctors advised them regarding professional cleanings before i went for cleaning services i felt afraid because i had never done that before i had never had a cleaning like that before but when i arrived there the doctor explained to me this and that and told me not to worry because it is normal and for the gynecological disease it requires some care of the vagina to be cleaned for us women it is very important another woman echoed this idea describing an interaction where she was told that a professional cleaning would prevent stis and maintain her hygiene they said it would prevent me from getting an sti and it would keep my hygiene good overall fews navigate a complex landscape of messaging about whether and how to clean cleaning may be a norm shared by their communities or family members it might also be a practice actively encouraged and supported by peers in the same profession those who do not use such practices may be frowned upon or judged by peers in addition health care providers responsible for providing gynecological care seem to offer somewhat mixed guidance fews report receiving mixed information from health care providers they are hearing that some aspects of ivp are beneficial while other aspects are not health care providers also appear to be offering professional cleaning services and discouraging athome cleaning cleaning process in the context of this complicated landscape women shared the practices they used to clean women used a diverse set of approaches and materials used to support cleaning they identified two modes of cleaning selfcleaning or the use of professional services these practices as described by participants are detailed below selfcleaning process selfcleaning is the practice of inserting materials into ones own vagina with the intention of cleaning the vagina and for some women the cervix or uterus as illustrated by the quotes below from interviews and fgds womens selfcleaning practices and the types of materials used vary we clean with tamarind water or saltwater a little bit warm and use a piece of soft cloth and use my hand to scrub and at the end i use the fresh warm water to clean it professional cleaning process professional cleaning involves a doctor or other provider in a healthcare setting such as a hospital or clinic inserting materials into a womans vagina for the purpose of cleaning the vagina cervix andor uterus women shared what happens during those sessions r they told me to go lay down on the bed and then they scrubbed with water then they cleaned the inside for me m when they cleaned inside for you what did they use to clean inside for you r the tweezer and they wore gloves they cleaned in a circle they used cloth the experience of being cleaned was described by some women as mildly painful or unpleasant while others described feeling fresh and clean as a result of the cleaning i changed my clothes then the doctor started cleaning my uterus i felt very fresh and clean unlike before i went there while some women exclusively practiced selfcleaning or professional services other women indicated a cyclical relationship between selfcleaning and professional services r1 some women clean only the outside but then the inside is still not clean r2 we can clean only the outside so we want to get cleaned on the inside at the hospital once a week frequency of cleaning some women described selfcleaning as part of their daily or weekly routines and professional cleaning at regular intervals others described cleaning as something they did before and or after sex with partners or clients we washed immediately after sex to flush out the semen after 30mn or 1h male gamete would not come out impact of cleaning women had many ideas about the impact of cleaning the ideas included the promotion of hygiene the prevention of infection the treatment of existing issues and the experiences of stigma and discrimination when getting professional cleaning services cleaning also gave fews to feel a sense of responsibility confidence and control promotion of hygiene and prevention of infection women described how they used cleaning as a part of a routine to maintain health and hygiene health and hygiene was the most commonly cited reason for cleaning some women described routines as a general practice while others connected the routines to the specific context of their work prevention of vaginal health issues both selfcleaning and professional cleaning were identified as necessary to prevent vaginal health issues like infections discharge inflammation stis and fungus in the quotes below women described how they used cleaning to prevent irritation or discharge that may result from sex work because we have lots of clients thats why we need to clean if we did not clean we would have discharge or irritation in severe cases other women thought that washing could prevent stis sometimes condoms break but then i washed immediately i want to know if i washed immediately right after having unprotected sex does it prevent hiv transmission treatment of an existing issue both athome and professional cleaning were commonly discussed for the treatment of vaginal health problems both were seen as effective at treating inflammation stis discharge itching smell and leucorrhea when i had it referring to itchiness i mixed salt lemon and water then i washed my genital area with itafter washing with it i did not have itchiness anymore sense of confidence women who reported cleaning in the absence of any physical symptoms said they did so because they wanted to feel confident clean and fresh womens descriptions of ivps as a good thing to do or as something they just want to do for themselves suggest a sense of ownership and control over their participation selfcleaning was perceived by some women as an exercise in selfsufficiency enabling them to practice selfcare without needing to rely on medical resources the ability to take care of ones vaginal health without having to put ones faith in others was presented as necessary r we felt cleaned and confident after we got the cleaning service experiences of stigma and discrimination women described how when they went for professional cleaning they or their friends were treated poorly by providers the women below described the various ways providers may stigmatize them sometimes the doctor said he did not want to help them since we were too dirty r1 they referring to doctors did not care when we hurt since they knew we came from the organization and so we must be the fews r2 some doctors said that without proper washing first they did not want to clean us when i got washed at the hospital the doctor used such bad words to me and used lots of force and hurt me descriptions of acts where doctors call them dirty deny them services until they were considered clean enough to receive care blame them for their health problems or are unnecessarily rough in providing services were present in most fgds discussion this study describes the complicated roles of intravaginal practices in the lives of fews in cambodia the themes of internalized and enacted stigma emerged as a motivation to clean a source of pressure from peers to practice internal cleaning and a consequence of seeking cleaning services by health providers in summary fews described a complex landscape of motivations and behaviors around ivps this included whether to clean how to clean and when to clean if they choose not to clean they fear repercussions about how others perceive them in their communities if they choose to clean they may be harming themselves or experience stigmatizing care by a health professional as in our study other studies from around the world have found that discrimination and disrespect from health care providers towards entertainment and sex workers is a significant barrier to healthcare access especially for hivsti testing and treatment 28 29 30 31 32 fewer studies have found internalized stigma and peer pressure as motivations for personal behaviors such as ivps as we found nevertheless one study from china found that vaginal cleansing rituals were an essential part of maintaining a clean image among sex workers they also noted that one who does not practice these daily cleanings was condemned for the consequences of her behavior 33 our study found that women reported cleaning themselves frequently and this was directly related to sex with clients a crosssectional study among cambodian fews in 2015 found that douching which typically indicates washing the outside of the vagina was practiced among 91 of respondents usually right after sex especially among those who engaged in transactional sex 34 another qualitative study found a clear and close connection between ivps and sex work among the same population 3 in our study fews discussed one motivation for ivps being the prevention or treatment of infections particularly stis much of the medical literature around ivps suggests that these practices are not associated with the prevention or treatment of infections 1 a study on the effectiveness of an ivp cessation intervention among women living with hiv in kenya found a decrease in vaginal candidiasis after three months of the cessation of ivp 22 a crosssectional study among 200 fews in cambodia found that intravaginal washing in the past three months was not associated with lower hpv genotypes collected through selfcollected specimens 35 further investigation of the role of ivps in disease transmission is warranted our study suggests that local health providers are giving mixed messages and more importantly delivering discriminatory care to fews women talked about providers telling them both that they do not need to practice ivp while also providing them cleaning services this suggests that providers may need more support in delivering messaging that is clear and informative it is possible that providers are saying they are providing cleaning services while in reality providing other services such as checking for stis this area needs more investigation the one other published qualitative study which details ivps among fews in cambodia suggests that health providers may be agents to change ivps and an effective channel to deliver interventions 3 our findings suggest that health providers were often discriminatory towards fews and promoted mixed messages about ivps we anticipate that much work would need to be done with providers before they can be true advocates for fews and deliver healthy and respectful messages around ivps interpretation of study findings are limited by some important factors including our sampling strategy and our data collection tools we recruited participants using purposive sampling and therefore our findings are not generalizable to the entire population of fews those who participated may have been more connected to ongoing health and outreach programs and therefore might have more information about ivp and cleaning practices as such our findings may under represent the lived experiences of fews with less information about ivp in addition our data collection tools were not validated tools because we could not find existing tools that were relevant as a result our questions may be leading or biased in some way that we did not intend in response we note that participants did not appear to be uncomfortable answering questions about ivp and conversation flowed smoothly conclusions our findings suggest that ivps are widely practiced among fews in cambodia and associated with internalized and enacted stigma highly stigmatized practices may benefit from a harm reduction approacha strategy that aims to reduce harm associated with a certain behavior instead of trying to extinguish the behavior altogether for ivp an approach that emphasizes positive ivp practices among fews and health care providers including external cleaning for the physical and psychological benefits while discouraging internal cleaning without judgment coercion or discrimination this may be an important way to promote positive messages about the desire to feel clean as well as address some of the sources of internalized and enacted stigma in their lives abbreviations fews female entertainment workers fgd focus group discussions hiv human immunodeficiency virus idi indepth interviews ivp intravaginal practices sti sexually transmitted infections competing interests the authors declare that they have no conflict of interest

background intravaginal practices ivps methods used by women most often to manage vaginal hygiene and address perceived disruptions to vaginal health may increase the risk of contracting human immunodeficiency virus hiv and other sexually transmitted infections stis this qualitative study explores the social professional and peer context surrounding ivps the experiences of selfcleaning or getting cleaned from a health professional and the perceived impacts of ivps among female entertainment workers fews in cambodiain 2017 we conducted 27 focus group discussions from four provinces and 16 followup semistructured indepth interviews with purposively selected participants in two provinces data collection occurred over three weeks with concurrent data transcription and translation the data from the transcripts were analyzed using dedoose an online openaccess qualitative analysis software two researchers independently labeled sections of transcripts associated with broader categories and subcategories based on the initial content analysis matrix and created codes this process continued iteratively until a final coding schema and conceptual model was createdwe found that ivps are widely practiced among fews in cambodia and are associated with internalized and enacted stigma stigma was an overarching theme that impacted the subthemes of 1 messages about cleaning 2 the cleaning process and 3 the impact of cleaning experiences of enacted stigma and internalized stigma permeated conversations about ivp including feeling pressured by peers to keep themselves clean practicing internal cleaning after transactional sex and being called dirty by health providers conclusions fews who practice ivp talk about it in the context of their lived experiences stigma and discrimination highly stigmatized practices such as ivp among fews may benefit from a harm reduction approach that emphasizes positive changes without judgment coercion or discrimination

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i introduction agricultural extension plays a very important role in improving agricultural productivity in many countries including tanzania it is through agricultural extension farmers can recognize challenges antagonizing agriculture and understand agricultural opportunities which are very essential in making agricultural activities move from one stage to another moreover it is a system of adult education which help farmers to learn new and improved agricultural practices and make efficient utilization of the resources they have 1 2 from independence in 1961 to late 1998 agricultural extension services in tanzania were centralized the ministry of agriculture had a role to supervise and coordinate extension services provided in the entire country and the delivery of those services was mainly topdown this system made the ministry of agriculture use ministry staff to provide extension services with the workers located at the ministry regional and district levels the system did not work because farmers were not served according to their needs and preferences this is due to the reason that extension workers prioritized instructions given by their superiors rather than being accountable to their farmers 3 subsequently in 1999 delivery of agricultural extension services was decentralized to local governments whereby the local governments were given the mandate to supervise the provision of agricultural extension services at the local level 4 decentralization made the government recruit extension workers and ensured that there was at least one extension worker per village the major purpose of the government to decentralize agricultural extension services was to ensure services are brought closer to farmers and increase their participation in extension programming 3 4 regardless of the governments efforts to decentralize extension services experience shows that the system did not work as expected failing to articulate farmers needs 4 the presence of a few extension workers as compared to the number of farmers poor remuneration of extension staff and decline in government expenditures made the system weak one of the pieces of evidence is the failure to have one extension worker per village as recommended in the reform instead till today there are few numbers of extension workers as compared to farmers leading to low farmers access to extension services 5 subsequently because of these reasons and others the government realized that it could not continue to be the central provider of extension services the government decided to move from being the central provider toward a pluralistic system that brings different agricultural development stakeholders together in the provision of extension services 1 4 the argument for pluralism was based on the premise that the private sector comprising private companies nongovernmental organizations farmer organizations or specialized consulting firms can provide extension services more efficiently and effectively than public sector agencies and that these advantages increase the likelihood of longterm and sustainable services 6 to put much emphasis on the governments effort the agricultural sector development programme launched in 2017 explains that the major purpose of the government is to improve the quality and the provision of agricultural extension services by opening doors for other agricultural development stakeholders such as nongovernment organizations communitybased organizations and private agribusiness firms to participate in provision of demanddriven extension services rather than supplydriven 7 moreover 8 also emphasizes the provision of quality extension services with the increase of private sector involvement and ensuring both rural and urbanbased farmers have access to agricultural extension services provided by different providers 3 7 as stated earlier the government took those initiatives to improve extension services by allowing private agribusiness firms nongovernment organizations and communitybased organizations to participate in the provision of extension services to farmers however with the involvement of the private sector in the provision of extension services the government remains to be the major stakeholder the entire supervision and coordination of all activities performed by the private sector is done by the government in every respective district there is a district focal person who coordinates and supervises the operation of private providers of extension services regardless of the existence of these private organizations still rural farmers access to extension services provided by these private organizations has remained a main question studies have consistently pointed out that only a few farmers in rural areas get access to extension services provided by private organizations for example 9 conducted a study on smallholders demand and access to extension services among contracted cotton producers in northern tanzania and found that only 46 of farmers had access to extension services similarly 10 studied farmers access to and benefits of agricultural extension in the dodoma region and found that only 17 of respondents had limited access to extension services provided by different providers moreover various innovations such as improved seeds the use of fertilizers pesticides and postharvest technologies have not been adopted by the majority of smallholder farmers due to inadequate and inefficient delivery systems 11 agricultural sector review reported that 60 to 70 percent of smallholder farmers have no contact with extension services and for a long time this has resulted in low access to services among farmers in different places in tanzania low access to extension services by rural farmers has contributed to low agricultural production in rural areas and has remained the main reason for persistent poverty in rural areas a extension services in kibondo district kibondo district has various extension service providers with varying interests in supporting agricultural development ranging from those who are publicly owned to private providers of extension services the district has a total number of 33 public extension staff who work at different levels 8 staff at headquarters 13 staff at wards and 12 staff at the village level 12 as compared to the total population in the district which is 27 2431 with 87 of the population depending on agriculture for their livelihood 33 extension staff are not enough to serve all farmers in the entire district hence to support the governments efforts to improve farmers access to agricultural extension services in the district there are also private providers including tanzania youth agriculture development which provides agricultural training to youth kibondo environment management association which provides training about cassava production and fodder potatoes and world food program which provides training about postharvest handling of agricultural produces others are the danish refugee council which trains farmers in vegetable production and greenhouse construction relief for development society which trains farmers in irrigation agriculture and warehouses construction tanganyika christian refugee which provides training about irrigation agriculture and kigoma youth agriculture development organization which provides agricultural training kibondo district has a total number of fifteen private organizations due to the presence of refugee camps most of these organizations invest much effort in helping and serving refugees in their refugee camps although this does not limit them from working with other groups in the district as a result some of the communities around refugee camps also benefit from services provided by private organizations within those communities only few farmers access extension services from private organizations however to improve rural farmers access to extension services it is important to understand the current access level and factors influencing farmers access to extension services this will help the government and other agricultural development stakeholders to take appropriate measures to ensure that the level of access to extension services among farmers increases this study aimed to determine the access to extension services by rural farmers and the factors influencing rural farmers access to agricultural extension services provided by private organizations in kibondo district ii methodology a description of the study 𝐴 𝜋𝑟 2 this study was conducted in kibondo district in kigoma region tanzania the district is located in the northern part of the region with about 836484 km 2 of land size according to the kibondo district council five fiveyear strategic plan for 20162022 in 2021 the district had a total population of 272 431 and 87 of the population engaged in agriculture this shows that the majority of people in the district depend on agriculture for their livelihood the district is estimated to have over 221593 km 2 of potential cultivatable fertile land and it has favourable climatic conditions which allow the growth of a wide range of variety of both food and cash crops the district has a total of 33 public agricultural extension staff whereby 8 are at the district headquarters 13 are at the ward and 12 are at the village level 12 the district was selected for the study due to the presence of a large number of private organizations which provide various extension services to host communities and refugees camps b sampling procedures and sample size the study adopted a multistage sampling procedure whereby the district was purposively selected due to the presence of private organizations that provide extension services to farmers then four wards were randomly selected from the list of wards obtained from the districts office thereafter one village from each ward was purposively selected to make a total of four villages the researcher was provided with the village register book from each village and randomly selected 120 households for the study that is 30 households from each of the four villages the sampling frame was a household and the target population was one adult member of the households in every selected household it is recommended that a sample size of 80120 respondents is significant enough to carry out socioeconomic studies in subsaharan african countries including tanzania 13 14 c data collection procedures the study used a crosssectional research design whereby data were collected at one point in time from selected samples before data collection enumerators were trained on procedures for data collection and questionnaires were first pretested to identify some technical mistakes and make corrections ensuring the tool is simple appropriate and it is not timeconsuming then 120 smallholder farmers were interviewed by using semistructured questionnaires regarding farmers access to agricultural extension services provided by private organizations the study also used an interview guide for key informants including managers and directors of private organizations and public extension workers to provide more information about their general performance and coordination of all activities carried out in the district additionally three focus group discussions with farmers were conducted in the study area using a checklist d data processing and analysis after data collection quantitative data were recorded entered into the computer cleaned and finally analysed by using statistical package for social sciences version 20 software descriptive statistics such as frequency and percentage were computed to determine the proportion of farmers who had access to agricultural extension services a binary logistic regression model was used to determine factors influencing rural farmers access to extension services provided by private organizations access to extension services was coded as 1 and no access was coded as 0 previous studies 15 18 have reported that binary logistic and probit regression models fit in explaining the relationship between dependent and independent variables however 15 declared that the binary logistic regression model is much preferred by a researcher over the probit regression model since the binary model is easier to use and provides a more meaningful interpretation of the results than the other models binary logistic regression was employed in this study based on the advantages that it has over the probit model some of the previous studies that adopted the binary logistic regression model include 14 19 23 the binary logistic model and its interpretation are shown below log 𝑝 1𝑝 𝛽 0 𝛽 1 𝑋 1 𝛽 2 𝑋 2 𝛽 3 𝑋 3 𝛽 4 𝑋 4 𝛽 5 𝑋 5 ⋯ … … … … … 𝛽 𝑛 𝑋 𝑛 𝜀 where p is the probability of a farmer accessing extension services p1 is the probability that a farmer is not accessing extension services 𝛽 0 yintercept 𝛽 regression coefficient 𝜀error term 𝑋 1 … 𝑋 𝑛 independent variables e conceptual framework in this study the word access is defined as the ability of a farmer to easily use or utilize extension services from private organizations to improve agricultural production the conceptual framework is derived from a socioecological model by 24 it explains the relationship between dependent and independent variables the dependent variable is access and independent variables include farmers related factors such as age gender education level marital status farmers income household size farming experience credit access and distance others are farmrelated factors such as farm size and group membership which is considered as the community factor based on the review of previous studies these factors may either positively or negatively influence farmers access to extension services iii results and discussion the study results show that females account for 6080 and males account for 3920 of respondents having more females in the sample than males doesnt mean that some households did not have any male adults it is because most of them were not at home by the time interviews were conducted this result is in line with 10 who conducted a study on access to and benefits of agricultural extension in tanzania particularly in the dodoma region the results show that twothirds of the respondents were females accounting for 6638 and onethird of respondents were males 3362 the age of respondents ranged between 20 to 87 years with mean and standard deviation of 4378 and 1582 respectively the respondents mean age of 4378 indicates that the majority of respondents were still energetic and had the power to engage in agricultural activities 10 and 21 declared that farmers whose ages range from 25 to 47 years are active and have a great chance to participate in agricultural activities and this might increase the chance of accessing extension services to produce more independent variable dependent variable fig 1 conceptual framework about education level the majority of respondents had attained formal education education helps farmers to be aware of various agricultural opportunities which are essential in improving agricultural production for example a farmer will be able to search for new improved seeds as they know the importance of using them moreover education increases farmers ability especially in making decisions for seeking demanddriven extension services because they understand well their needs 25 and 19 explained that educated farmers can search for new opportunities in agriculture that fit their needs to improve their agricultural production in terms of marital status the majority of respondents were married while 233 were not it is believed that there is much information flow and sharing among married farmers as compared to unmarried ones this enables them to be informed with daytoday news concerning wider issues in agriculture such as newly improved seeds crops that have high prices currently in the market extension services that are essential in improving agriculture production etc furthermore farmers who are married can work together as a team to accomplish certain tasks 26 reported that married farmers have a great chance of being successful as most of them depend on family labor they depend on each other in whatever they are doing the results also revealed that 9580 of respondents had no access to credit for farmers to be able to increase agricultural production credit access becomes very important this is because credit helps them to purchase agricultural inputs such as seeds fertilizers pesticides and agricultural equipment for production lack of credits hinders farmers from producing more because agricultural inputs are not sufficient for production credit access is associated with agricultural productivity and that lack of credit hinders the purchase of agricultural inputs which results in low productivity 27 28 concerning household size the results show that on average 6 people stayed in one household the majority of respondents spent more than thirteen years in agricultural activities which is a sign of long experience in agricultural activities a access to and types of extension services this part aimed at discussing the level of farmers access to agricultural extension services and the types of extension services that farmers received from providers the intention was to understand the types of extension services and the level of access to those services the results from table iii show the access level of agricultural extension services and the types of extension services received by farmers the results show that out of sampled smallholder farmers only 183 had access to extension services the problem of low levels of access has also been reported by other scholars in different parts of the world to point out a few examples 21 did a study on socioeconomic factors influencing access to agricultural extension services among smallholder farmers in western uganda the study found that only 425 of respondents had access to extension services similarly a study by 21 on determinants of access to training on postharvest loss management among maize farmers in uganda found that only 42 of respondents had access to postharvest training that was provided by the extension agents furthermore the study on smallholders demand for and access to private sector extension services among contracted cotton producers in northern tanzania by 9 revealed that only 46 of respondents had access to extension services from private providers the study by 10 on access to and benefit of agricultural extension in tanzania particularly in dodoma region found that only 17 of respondents accessed extension services on the types of extension services there were five major types of extension services these include technical services input services financial services marketing services and transportation services among all farmers who had access to extension services from private organizations all 22 farmers accessed technical services which account for 100 input services account for 818 financial services account for 227 marketing services account for 182 and transportation services account for 46 b factors influencing rural farmer access to agricultural extension services from private organizations access to agricultural extension services was regressed against a set of independent variables the variables were tested at a 95 significance level to determine the fitness of the model the following major key issues were assessed pseudorsquared pvalue of the model and loglikelihood from our binary logistic regression model the pvalue of model fit is prob chi 2 0000 which is less than 005 which indicates that independent variables influence the dependent variable the pseudorsquared value is 265 and the loglikelihood ratio value is 80282 29 explain that a good range of pseudorsquared values should range from 20 to 40 therefore based on those particular recommendations of the model its concluded that the results of the model fit adequately for this study the coefficient for gender was negative and statistically significant with the coefficient and odds ratio of 1807 and 0164 respectively the negative sign indicates that being male decreases the chance of accessing extension services and the odds ratio suggests that access to extension services from private organizations is lower among male farmers than female farmers this may be due to the fact that most private organizations prefer working with farmers who are in groups and in most cases females account for a large percentage in those groups as compared to males likewise experience shows that females are always interested in joining various groups such as agriculturalrelated groups because they see benefits obtained from the group the finding is consistent with the finding of 30 who reported a negative effect of gender on access to extension services however the findings are inconsistent with 21 and 19 who reported a positive effect of gender on access to extension services this may be attributed to the fact that males are quick and always consistently wellinformed about agriculture programs such as extension services moreover these studies pointed out that females are less likely to access extension services since in most developing countries women are poor and marginalized due to social and cultural practices which hinder them from accessing production resources such as land and credits and this affects their access to extension services this finding has contradictory since some of the studies found positive and some negative associations between gender and access to extension services these differences might be due to different contexts or areas where the studies have been conducted education level was positive and statistically significant associated with access to extension services with the coefficient and odds ratio of 0973 and 2646 respectively this displays that farmers who are educated have more chance of accessing agricultural extension services than noneducated counterparts that is access to extension services is 2646 times greater for educated farmers as compared to noneducated farmers this is because education helps farmers to understand wider issues related to agriculture increases farmers curiosity toward new technologies and develops a desire to try new technologies which are potential in agriculture likewise education raises farmers awareness to understand new opportunities that arise in agriculture and make effective use of them in improving agriculture production this finding conforms with other findings 16 19 21 23 reported that education is a form of empowerment and is a social capital that once a farmer has it increases the desire to search for more extension services it is assumed that farmer who is educated know the importance of agricultural extension services and hence should be able to search for them to improve agricultural production the association between marital status and access to extension services was positive and statistically significant with the coefficient and odds ratio of 3320 and 2661 respectively married farmers have a higher chance of accessing agricultural extension services as compared to their counterparts that is access to extension services is 2661 times greater for married farmers as opposed to unmarried ones this is because married farmers have the opportunity to share ideas and distribute family roles and responsibilities among family members which increases the chance of success when it comes to agricultural activities married farmers may be able to work together and share different ideas on how to improve agricultural production and make decisions on what extension services are needed to improve their agricultural productivity this finding is consistent with the findings reported by 31 32 and 21 that access to extension services is much higher among married farmers since there is much information sharing and encouragement among family members farm size was also positive and statistically significant related to access to agricultural extension services with the model coefficient and odds ratio of 0318 and 1374 respectively the likelihood of accessing extension services is 1374 times greater among farmers with a large portion of land as compared to farmers with a small land portion this could be because farmers with large portions of land have a desire to produce not only food crops but also cash crops for income generation to sustain their lives and this made them search for more extension services to meet their goal similar findings were reported by 19 21 and 22 that farmers who own large portions of land have more access to extension services as most of them produce for sale hence they require various extension services to produce products of good quality group membership is positive and statistically significant associated with access to extension services with a coefficient of 6565 and an odds ratio of 7097 the odds ratio suggests that access to extension services is 7097 times greater for farmers with group membership as compared to nongroup members this could be due to the reason that many agricultural opportunities reach farmers who are in groups and in most cases due to the inadequacy of extension agents contacts in many cases are done through farmers groups it is in the same way as in extension services from private organizations farmers who benefit from those services are the ones who have group membership furthermore the director of a private organization during the interview was quoted as saying agricultural associations have been the best way that ease the provision of extension services to farmers in most cases farmers who access our extension services are the ones who belong to a group it is very difficult for us to reach an individual farmer due to the financial problems of the organization that is why we prefer working with farmers who belong to a certain group 19 21 and 22 reported that group membership significantly influences farmers access to extension services since most farmers prefer joining agriculturalrelated groups for the purpose of sharing and exchanging agriculturalrelated ideas which are very essential in improving agricultural production and easy accessibility of extension services to farmers this implies that farmer being in any farmers association might increase accessibility to extension services given the fact that private organization budget is very limited iv conclusion the study concludes that the issue of access to agricultural extension services among farmers is still a big concern that needs to be taken into consideration by the government and private providers of extension services the findings reveal that access to agricultural extension services from private organizations is still very low among farmers in the study area and this is attributed by various factors such as gender education level marital status farm size and group membership thus the problem of low access to extension services cannot be solved unless all these factors are taken into consideration by the government and private organizations v recommendations therefore the study recommends that i the government should implement adult learning initiatives through agricultural extension to assist farmers who were unable to attend school in learning how to read and write through the development of their knowledge and abilities they will be able to comprehend the significance of agricultural extension ii farmers should be encouraged to form and join farmers associations in order for them to easily access extension services from various agricultural extension services providers iii reinforcing gendersensitive approaches to enable men to access extension services encouraging males to join in farmers associations will help them also to access extension services as females iv farmers should be encouraged and motivated to own large farm portions and if possible the government should distribute some land which are claimed to be the government land so that farmers may be able to cultivate them this might increase farmers desire to seek extension services from various providers v the government should improve rural infrastructures such as roads especially in rural areas this will enable private providers to reach rural farmers easily and hence more farmers will have access to extension services conflict of interest the authors declare that they do not have any conflict of interest

agricultural extension plays a very important role in improving agricultural productivity in many countries including tanzania through agricultural extension services farmers acquire useful information to minimize agricultural production challenges though farmers in many countries including tanzania still rely on public extension services the governments in many countries have started to open doors for nongovernmental organizations ngos farmerbased organizations and private agribusiness firms to provide services to farmers regardless of their existence still access to extension services provided by private organizations has remained a main question studies have consistently pointed out that only a few farmers in rural areas get access to extension services provided by private organizations low access to extension services by rural farmers has contributed to low agricultural production in rural areas and has remained the main factor for persistent poverty there are limited studies documenting the factors for low access to agricultural extension services provided by private organizations this study aimed to determine factors influencing rural farmers access to agricultural extension services provided by private organizations in the kibondo district the study used a crosssectional research design and data were collected by interviewing 120 farmers sampled from four villages data were analyzed using descriptive statistics and binary logistic regression model techniques the study found that only 183 of farmers had access to extension services gender marital status education level farmers income and group membership had a positive and statistically significant association with access to extension services the study concluded that only a small proportion of rural farmers in the study area had access to extension services it is recommended that the provision of extension services by private organizations should consider the identified factors

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introduction autism spectrum disorder is a complex neurological and developmental disorder that involves persistent developmental challenges causing mild to significant levels of impairment in speech nonverbal communication social interaction and behavior 1 2 3 while there has been an increase in the prevalence of asd globally over the last two decades 4 the vast preponderance of research has been conducted in western highincome countries essentially ignoring the experiences of 80 of the worlds population 5 the global prevalence of asd has been estimated to be between 12 of the population 67 and evidence shows heterogeneity of prevalence estimates of asd across different geographic areas due to different methodologies that are being applied in case detection 8 and sources of data used to estimate prevalence 4 yet the rates of asd prevalence and its comorbidities in lowand middleincome countries are largely unknown due to limited resources scarce knowledge of asd and weak healthcare systems 910 parents whose child is diagnosed with asd face multifaceted difficulties including economic burden related to income loss and high costs of rehabilitation 1112 less time for leisure and entertainment 13 altered family dynamics and frequent parental conflicts 14 and problematic behaviors and distressing emotions 15 when compared to parents of children with other developmental disabilities parents of children with asd report higher levels of stress 16 a burden largely borne by mothers 317 and more mental health problems including depression and anxiety 1819 while they may experience higher levels of stress support from family and friends or other support such as professional guidance 52021 as well as looking for positives in the experience 22 serve as buffers in overcoming stress mothers employ various coping strategies including active avoidance coping positive coping problemfocused coping and religiousdenial coping 23 parental experiences of raising a child with asd vary according to contexts including location family size marital and occupational status social support and socioeconomic conditions 91724 the bulk of research on the parental experiences of raising a child with asd however has been conducted in western and highincome countries with few studies in lowand middleincome countries 525 little is known in lowandmiddle income countries about the parental experiences of raising a child with asd 42627 the limited research that exists reports that parents have limited awareness of the diagnosis and a lack of access to information and education on asd 2829 not knowing how to help their child with asd contributes to their distress strain on the marital relationship and poor parenting in resourcepoor countries raising a child with asd and other types of mental disorder is more challenging and complex due to a lack of diagnostic and educational services and due to limited parental awareness recent studies have described the experiences of parents of children with asd in nepal where parents and healthcare providers have little awareness of the illness 30 and in india where mental illness and disability have historically been kept hidden largely as a result of stigma 3132 in egypt to care for a child with asd was found to be daunting and overwhelming to parents due to a lack of awareness as well as due to minimal or even absent services for children with asd 33 in jordan the most common challenges that parents faced in caring for their children with asd were a lack of public awareness about asd financial burdens on parents and limited specialized knowledge among healthcare providers about asd 34 unravelling mothers experiences of caring for a child with asd is crucial to facilitate effective interventions this is particularly important as research that focuses on maternal experiences of caring for children with asd is rarely addressed in lowand middleincome countries 33 in the current study using a qualitative methodological approach we investigated the experiences of mothers whose child was diagnosed with asd and who identified aspects of raising a child with this diagnosis the aim is to contribute to the growing research that documents parental experiences and coping mechanisms in raising a child with asd in the global south specifically shedding light on the experiences of ethiopian mothers studying the experiences of mothers is particularly important as they have a profound role in raising the child the study was guided by the following research questions a what are the experiences and reactions of mothers during and after the time of their childs diagnosis with asd in urban ethiopia b how did mothers of children with asd develop coping strategies to strengthen their resilience against stress in urban ethiopia the ethiopian context parental experiences in raising a child with asd in ethiopia considering the relevance of contributing to the limited but growing research that documents parental experiences of raising a child with asd in developing countries this study was conducted in ethiopia a country located in the horn of africa the second most populous country in africa ethiopia has a total population of over 120 million with children representing more than half of the population as there are no official statistics the prevalence of asd among ethiopian children is unknown ethiopia is among the least developed countries in the world with extremely limited mental healthcare facilities available as most of the ethiopian population lives in rural settings diagnostic and treatment services to children with asd are largely nonexistent 3536 the very few available educational and diagnostic services for children with asd are concentrated in the countrys capital addis ababa 27 to overcome the problems of low coverage of mental health services in rural ethiopia in 2003 the ministry of health implemented a communitybased mental health services model as part of the health extension program 35 over 38000 health extension workers who completed a oneyear basic health training course have been deployed throughout rural ethiopia providing primary healthcare services with health promotion and prevention packages through this strategy mental healthcare services are provided by nonspecialist hews 37 although not trained to diagnose and treat mental health problems the hews have played a vital role in ensuring decentralized care provision which has been found to be promising as a support for parents who have children with asd 36 social workers are increasingly recognized to be working in the ethiopian healthcare system and hospital settings social work practice in ethiopia is very different however from the established practices in resourcerich countries in the global north informed by the biopsychosocialspiritual model social work practices in many developed countries center the mental health needs of individuals families groups and communities 38 in contrast social workers in ethiopia do not commonly deal with mental health issues rather much of the focus of social work practice in ethiopia is influenced by policy priorities and the governments political ideology informed by poverty reduction policies and strategies the areas of practice for many of the ethiopian social workers have recently included social protection and poverty reduction many social workers practice social welfare in ngos and to a lesser extent in hospital settings consequently the lack of professional healthcare workers including mental health social work practitioners has affected service provision to children with asd and their parents after interviewing service providers in ethiopia tekola and colleagues concluded that services for children with asd are extremely limited and that stigma and lack of awareness are impediments to overcome 27 the bulk of care consequently falls to families and in particular mothers despite occupying a lower socioeconomic status and being excluded from decisionmaking roles in families communities and organizations women in ethiopia often play an instrumental role in family and community affairs including raising children with asd an emerging research literature reports the challenges mothers face in raising a child with asd including spousal abandonment 39 quitting their jobs to care for the child 40 and social stigma 36 many mothers are reluctant to leave their children with relatives or neighbors because their childs behaviors are typically misunderstood and considered a result of either poor parenting or punishment for sin talking about their children can be difficult as mothers may feel guilt and shame they also fear social stigma which greatly affects the lives of children with asd children with asd are among the most disadvantaged social groups because physical and mental impairments are frequently viewed by ethiopian society as related to such factors as a curse or bad omen 41 thousands of children with asd are confined to their homes with little access to education and rehabilitation 27 educating a child with asd is not a priority in a country with pervasive social stigma furthermore the problems are compounded by the lack of awareness of many professionals in the medical educational and vocational fields regarding how to effectively work with individuals with asd 2936 there are however cultural resources that can be utilized to increase awareness of asd and reduce stigmatization weldeab and opdal noted that some traditional practices in ethiopia can be used as sources for change 41 for instance social gatherings can be a space for dialogue through which societal awareness can be increased indigenous social institutions and selfhelp associations established by community members to facilitate social insurance and economic support can be spaces in which to increase awareness and challenge the negative stereotypes of asd theoretical lens mothering in the current study the theoretical lens is based on the scholarly work of barlow and chapin in which mothering is understood as an emergent process that relates to the practices in which women participate by virtue of being a mother 42 although the practice of mothering is key in the construction of gender roles social status kinship and identity it is shaped by specific social contexts that vary based on material and cultural resources and constraints 43 mothering thus has multiple and often shifting meanings according to time and place 44 while theoretical discussions on mothering abound few studies analyze the challenges of developmental disorders on parents using the concept of mothering the theoretical lens of mothering is therefore operationalized in the current study as a means to understand the cognitive psychosocial and emotional processes of change that mothers experience when their child is diagnosed with asd 45 methods using a qualitative research design 46 data for the current study were collected by the first and second authors using semistructured interviews the interviews aimed at developing insight into the understanding and experiences of mothers in urban ethiopia who have children with asd interviews of 3040 min in length were conducted either through facetoface interactions with the mothers or via telephone following an interview guide interviews were conducted in the amharic language to allow for the broadest participation and to capture participant views in the language of their experiences all interviews were tape recorded and transcribed originally transcribed in amharic the transcripts were then translated into english the tapes and transcripts were stored in a safe place that was only accessible to the researchers ethical approval was obtained from the ethics committee of addis ababa universitys college of social sciences following a verbal description of the study all participants provided oral consent to take part this consent was recorded and transcribed to conceal the participants identities pseudonyms are used in this manuscript to recruit the participants we approached two civil society organizations that provide support to children with asd and their parents the support provided by these agencies includes treating children training parents in raising their children and providing day care services most support is free with some financial contributions from parents based on capacity and willingness to pay purposive sampling was utilized in selecting participants the selection criteria included mothers who were raising a child with asd mothers who provided care to their child with asd for more than two years mothers who were willing to take part in the research and mothers who received services from bright and joy autism centers data analysis data were analyzed using thematic analysis to understand how mothers of children with asd make sense of their personal and social worlds the transcripts were read repeatedly to familiarize the researchers with the data next significant statements were identified using the selective highlighting approach 47 which entailed choosing and highlighting key words phrases and sentences that significantly stood out and illustrated common experiences significant statements were coded and the coded data were analyzed to identify major themes through this thematic analysis we extracted three themes that best exemplified mothers experiences of raising a child with asd trustworthiness trustworthiness in qualitative research has traditionally focused on verisimilitude or the appearance of truth 48 that is achieving a sense of resonance or congruence with the audience that may have experienced similar situations 49 an additional suggested criterion is the utility of the narrative in terms of assisting with comprehending an experience and enhancing a groups future problem solving 50 in the current study the authors engaged in extensive rereading of the interview transcripts and checked for the accuracy of translation of the interview transcripts from amharic to english as the data analysis process unfolded emerging themes were discussed with expert peers and compared with the existing literature the authors also verified the credibility of findings by having discussions with selected mothers and doublechecking that the identified themes properly captured their experiences in this respect our forms of trustworthiness included prolonged engagement triangulation peer validation and member checking 5051 results in this section the extracted themes and subthemes of the study are presented including mothers emotional reactions during the diagnosis of their child with asd their cognitive responses after diagnosis which involves defining asd and acceptance of their childs mental health status and finally how they have developed new mothering practices through reframing their relationships with their child who has asd and identified positive learning experiences throughout this section pseudonyms are used to add a human face to the experiences of the mothers while protecting their identity shock and grief emotional reactions to diagnosis prior to receiving their childs diagnosis of asd many participants described having sought appointments at various medical centers seeing numerous doctorspediatricians and other healthcare professionals to understand the nature of the challenges they witnessed in their child and seeking assistance to address these challenges our findings show that during the investigative and diagnostic process mothers experienced an emotional rollercoaster including sadness and despair after receiving a diagnosis of asd for their child the participants described a grieflike process whereby they felt they had lost or were losing their child they reported myriad responses including hopelessness and shock and described asking why me for instance ayelu explained that she cried dagmawit said she felt shocked and numb and kebebush felt confused many participants said they asked god why their child was selected to have asd having described her childs behaviors enatenesh expressed when i knew it was asd there was no way out i was so distressed depressed and felt despair i asked god lemin enen the participants described feeling overwhelmed by the prospect of this diagnosis with little information medical support or referrals lulit revealed feeling devastated and helpless upon hearing her child had asd she explained that she was 14 and unwed about which her family was unhappy having a child with asd was overwhelming and an extra burden defining asd cognitive understanding and meaningmaking determining the causes of asd emerged in the analysis of the interviews as a meaningmaking process that shaped the participants maternal thinking and practice in most instances the mothers assumptions about the causes of asd negatively affected their worldviews including feeling that they were losing their child the participants struggles to make meaning of their childs diagnosis was an extended process in which they interpreted and acted upon experiences related to their child for example while wolansas child was diagnosed with asd in 2014 six years prior to the study she exclaimed there are not enough words to define autism she referred to the stigma as well as the financial and lifestyle burdens and depicted asd as a dreadful kind of disorder adding i feel like i am living in another new world sable similarly depicted asd as a terrible disorder she explained due to autism my daughter knows very little about her surroundings this cold truth makes me live in a dark state of mind there is little awareness of asd in ethiopia 36 several mothers reported having limited information at the time of their childs diagnosis with asd and none of the participants reported receiving counseling either during or after the diagnosis there is an acute shortage of professionals in ethiopia trained to provide services to children and their families who are affected by a developmental disorder 27 the few available healthcare services are in urban areas and are expensive mothers therefore found it difficult to know how to access information or treatment and services for example although kelemua had not heard the term autism before hearing her childs diagnosis she was not provided information or psychological support explaining that she was just prescribed medication to help her child sleep kelemua commented i really did not know what to do and where to go another participant demeku explained that even though she had been working as a nurse for several years she was unable to comprehend her situation she worried about what she was going to do and about what her son would become she explained that she felt like i was left in an isolated island no one lifted me no satisfactory information it was also very difficult to find an autism center that provides support in our country the meaningmaking process entailed participants searching for the causes of asd as presented in figure 1 the participants reported a range of possible causes that resulted in their child developing asd the mothers reported gods intention as the most frequent cause for having exposed their child to asd accordingly several mothers turned to religious coping so their child could be healed by supernatural powers mastewal explained that her son was born healthy with no problems during delivery his development was normal until he was two years she explained that an act of god was needed to change her childs mental health condition likewise kelemua reported that she did not do anything wrong during her pregnancy and that the fetus was healthy noting that her son was okay until the age of three years she similarly believed her son developed asd as a punishment from god because of a sin by her family two mothers were teenagers when they gave birth which they each thought could be the cause of their childs asd as noted above lulit was 14 years when she gave birth as her father refused to see her anymore she left her parents home and lived on the street during the first seven months of her pregnancy while her mother tried to help her when she could lulit could not care for herself during the pregnancy she believes that if she had regular medical checkups and family support her daughter would not have been diagnosed with asd other causes of asd were attributed to the actual birth premature birth was one factor believed to have caused their childs asd according to one participant oxygen could not flow adequately to her babys brain due to respiratory distress and breathing difficulties another factor according to one participant entailed the medical mistakes nurses made during delivery other mothers believed the cause of their childs asd was genetic predisposition as evidenced for example by several children in the extended family also having a developmental disorder less common reasons included the childs exposure to asd due to contraceptive pills taken early in the pregnancy or to chemicals and drugs during the pregnancy because of their work acceptance coping and moving forward after experiencing prolonged emotional reactions and defining the causes of asd in their own terms several participants commented that they accepted their childs status they found acceptance particularly important in facilitating their emotional transition from despair to hope boosting their resilience developing coping strategies and adopting new mothering practices they began considering their childs condition as unique rather than pathological silanchi relayed that over time she realized that children with asd are unique she expanded that while her child could fix metals and open any locked door he could not open his water bottle she concluded that asd was not a disorder but rather it is just uniqueness the only thing the autistic children expected from us is to understand them in my case i just moved forward to train my boy and to let him be the best person in the world meselech similarly talked about coming to accept her childs asd she explained that while it took her a long time to align her lifestyle with her childs needs she began to change her mindset as well as her home setting i accepted it i decided to change our lifestyle i shifted everything based on my childs needs i have to learn to let that go i learn to appreciate what he is doing new mothering reframing relationships with their child with asd many of the informant mothers revealed that they had begun to look forward after their child was diagnosed with asd and that they learned to employ various strategies to train their children to meet developmental milestones enatenesh relayed having to start from scratch to understand her childs emotional needs as she was juggling responsibilities as a researcher a wife and a mother of other children she stated that the experience of raising a child with asd is addis enatnet the participants believed this new mothering process changed their personality and worldview adaptation to new mothering required reframing goals adjusting behaviors and developing new life skills at the same time raising their other children influenced their understanding of motherhood mothering is a highly emotional and a deeply psychological process in which women develop close relationships with their children a shift in mothering practice has emotional economic social and psychological components what emerged in the analysis was a shift in the ways the participants acted and experienced being a mother after their child was diagnosed with asd a shift in the participants mothering practice began as a change in their everyday lives about half of the informant mothers left their jobs and became fulltime mothers and homemakers after their childs diagnosis with asd representative of these participants emnet quit her job to care for her child following the diagnosis of asd twelve years earlier she has a college degree from addis ababa university and had a wellpaying job in a private company with emnets spouse currently the familys only source of income this shift in mothering practice had economic effects as well as effects in other ways and areas some participants initially found it difficult to form an attachment with their child as they did not know what parenting style could work these women described focusing on their child and putting the childs needs first for example one participant began to recognize what set him off what calmed him down she described her child as still fairly nonverbal and he likes to be alone it can sometimes be difficult to understand what his needs are yet we have our own ways of connecting and having fun with each other wolansa was dedicated to helping her son learn life skills for example brushing his teeth which meant telling and showing him she noted teaching basic life skills takes and needs a lot of energy and time as i experienced it it also makes me feel closer to him another participant similarly found it was necessary to speak clearly to her child and to perform some important activities with him so that he could understand her and learn necessary life skills for example following a toilet routine for several participants particularly those who were working feeling emotionally connected with their child who had asd was time consuming and required considerable effort for serkadis new motherhood increased her burdens her daily routine began by cooking breakfast for her family followed by taking her child to the autism center she later took him home after finishing chores and took care of him while performing other household activities she found this routine very depressing as there was no time to take care of herself another mother mastewal reported that raising her child with asd was a nightmare initially only after a long process of stress and adjustment did she slowly begin to reconstruct a new motherhood worldview and mothering practice silanchi likewise explained that with time she recognized that her child was totally different which helped her to understand his reactions and to develop patience in recognizing his needs and wants she said when you become a mom of an autistic child you need to be a researcher in order to understand your childs behavior and to figure out everything positive learning experiences and cognitive reframing despite the many challenges several participants described personal benefits that would not have been possible had they not had a child diagnosed with asd meselech explained that raising her child taught her time management and budgeting increased her patience and understanding and helped her to appreciate the small things in life according to the mothers it was difficult to learn these things meselech explained it was not easy to learn these things though i learned after lots of ups and downs passing through anger tears and anxiety my lifestyle is now changed and i know the priorities in my life kelemua concluded the most important thing i have learned is patience patience patience she added that she also became more empathic towards other children with developmental disorders discussion the current study investigated the experiences of mothers in ethiopia who are raising a child with asd the findings revealed that in response to their childs diagnosis with asd mothers initially experienced sadness and despair and that their extremely limited knowledge of asd prior to the diagnosis contributed to them feeling overwhelmed this finding is in line with studies examining the experiences of mothers of children with asd in other regions of the world 51724 52 53 54 these studies found that parents limited awareness of asd contributed to initial reactions of denial sorrow fear and shock and that parents who have children diagnosed with asd exhibit greater levels of mental health problems such as anxiety and depression 1819 as well as suicidal ideation 55 the mothers in the current study all reported having received very little psychological or mental health support or guidance from healthcare professionals 27 this has been a barrier in seeking treatment and services thereby adding to the mothers stress this finding is consistent with other studies in the subsaharan african context which show that parents are displeased by the limited information and services they receive from healthcare professionals during their childs diagnosis with asd 56 determining the cause of asd emerged as an important component of the meaningmaking process that shapes maternal thinking and practice associating the causes of asd with supernatural power is common in africa other studies 2641 reported that parents attributed the cause of having a child with asd to evil spirits punishment from god and witchcraft similarly some of the mothers who participated in the current study ascribed their childs diagnosis to gods intention studies have reported that the causes of asd can be traced to both genetic and environmental factors 265758 genetic inheritance labor complications viral infection during pregnancy problematic infant immunization organic brain defects and head trauma are presented as causes the mothers in the current study believed that the causes of having a child with asd included genetic inheritance complications during delivery lack of selfcare premature birth exposure to drugs and taking contraceptive pills during pregnancy two mothers believed the cause might be a lack of selfcare illness and complications during pregnancy this finding coincides with gardener and colleagues who reported that medical complications during pregnancy may increase the risk of having a child with asd 59 a key finding is that the diagnosis of a child with asd profoundly shifted the participants mothering roles and worldviews several mothers stated that after learning their childs diagnosis they found themselves living in a new world similarly hoogsteen and woodgate found that parents were in their own world for all aspects of daily living and challenges related to parenting a child with asd 60 all mothers in the current study explained that the diagnosis of their child led them to adopt a different lifestyle and to change the family dynamics as well as their relationship with their child some even used the term addis enatnet to describe the shift in the mothering role after the diagnosis of their child in an emotional and relational sense a shift in mothering practice is expressed through reframing maternal relations with the child who has asd the new motherhood experience enabled mothers to explore different ways of parenting and to learn life skills to help them manage multiple roles consistent with previous research 60 61 62 the findings of the current study showed that despite the challenges in their parenting roles several mothers felt they benefited in some ways including developing essential life skills such as patience and redefining their priorities they were also able to develop other important life skills such as industriousness appreciating the little things in life and increasing their empathy towards others many informant mothers described their childs positive contribution in this regard and to their lifelong journey as parents which is supported by previous research 62 the positive learning experiences boosted the mothers resilience helping them to cope specifically many mothers developed patience which greatly contributed to their ability to reframe their relationship with their child and thereby help them regain a sense of control over their life limitations the researchers recruited a relatively small number of mothers who had children with asd who were enrolled in two nongovernmental charity organizations located in two cities in ethiopia as a result the study has a limited scope in terms of revealing the experiences of mothers who live in rural areas and whose children receive support from other institutional settings additionally a key limitation of this study is it cannot capture all the different types of asds including all the core asd features and associated symptoms that children with asd display asd consists of diverse abilities and disabilities and the results of this study primarily correlate with mothers emotional distress and coping mechanisms this study could not cover all the dimensions of the communication levels between mothers and their child with asd and the childs functionality in addition as the informants were mothers the study omits the fathers perspectives thus providing only a partial story of parental experiences of raising children with asd implications for mental health social work practice the findings of this study align with the view that social work professionals need to continue engaging in a crossfertilization of concepts and ideas that originate in different fields of study including disability and gender studies an interdisciplinary team is necessary to address the multidimensional challenges faced by mothers in raising a child with asd in ethiopia as the mothers articulated they experienced psychosocial challenges during and after the diagnosis it is critical for social workers to collaborate with other professionals in hospital settings to provide appropriate mental health support and guidance about asd as well as strategies to handle child behavioral and mental health problems our findings particularly inform professionals in ethiopia working with families to understand the care burden of mothers in raising children with asd social workers can play a meaningful role in helping families that have children with asd through counseling support yet the findings of this study indicate that supporting families in ethiopia needs to go beyond counseling social workers may need to consider working with families to find alternative mechanisms in redistributing parental roles and easing the care burden that mothers carry as well as find ways to ensure that mothers and their child with asd are safeguarded from harm for professionals who work with the ethiopian diaspora the findings point to the importance of grounding their practice with a sound understanding of family dynamics and the influence of culture on the caring of children with asd as such in supporting diaspora families and in mobilizing support professionals may need to consider the meanings mothers attribute to their childs challenges how mothers carry the brunt of the burden and how their everyday lives and their motherhood worldviews are altered after their child is diagnosed with asd according to our findings the mothers identified the centrality of strengths capacities and potentials that enhance their resilience and ability to access and utilize support and resources from family members hospitals autism centers and religious organizations it is critical for social workers to facilitate access to resources to strengthen mothers resilience and to advocate for such resources as incomegenerating activities which can provide the mothers with the means of tackling their financial burdens importantly social workers must focus on the rights of these children in accessing education and services in order to improve their wellbeing further research is required to increase social workers understanding and ability to work with mothers raising children with asd in ethiopia research examining support systems is vital to provide an understanding of the areas in which clients feel supported and those in which more support is needed 63 research on the experiences of these new motherhood practices which uncover stressors needs difficulties and resilience will inform social workers in meeting the needs of mothers raising a child with asd children with asd and their mothers face many challenges in hospital settings despite the inclusion of mental health in the countrys national health policy children with asd and their mothers have not received sufficient support or treatment in healthcare settings further development and endorsement of mental health policy is thus necessary to ensure the responsibility and accountability of healthcare workers in hospital settings the current study revealed that mothers of children with asd experienced anxiety and depressive symptoms in addition to social workers healthcare institutions need to create mechanisms to provide psychological support for the mothers to reduce related emotional challenges or problems conclusions the current study illuminates the experience of mothers raising a child with asd from the mothers perspectives the diagnosis of their child with asd was not only emotionally difficult as several participants moved through a grieflike process in response but was compounded by the mothers lack of information on asd and their limited access to psychosocial support from healthcare professionals through a meaningmaking process several participants searched for the causes of asd and struggled to define asd on their own terms this process led to cognitive reframing and acceptance acceptance of their childs neurodevelopmental condition appears particularly critical in facilitating the mothers transition from despair to hope and in contributing to learning new mothering practices and adopting coping strategies importantly a new mothering role articulated by participants which entailed reframing goals adjusting behaviors and developing new life skills and lifestyles changed their worldview and methods of relating to their child new mothering is both due to positive learning experiences in raising their children and contributes to new learning including developing crucial skills in raising child with asd such as time management patience and empathy finally the findings suggest that the recognition of new mothering and mothers meaningmaking processes their stress coping mechanisms and resilience are essential to informing policies programs and counseling and other therapeutic efforts data availability statement the data presented in this study are available on request from the corresponding author on a reasonable request the data are not publically available due to privacy and ethical issues informed consent statement informed consent was obtained from all subjects involved in the study

autism spectrum disorder asd is a complex neurological and developmental disorder that has seen an increase in prevalence over the past two decades particularly in low and middleincome countries the purpose of the current paper is to examine the experiences of mothers in ethiopia raising a child with asd through employing a qualitative research design involving semistructured interviews with twenty mothers the experiences of mothers in this study fell into three thematic areas 1 grieving and experiencing other emotions arising from the diagnosis of their child 2 developing understanding and defining autism and 3 accepting the diagnosis and developing coping strategies for raising their child the findings revealed that raising a child with autism introduced a new lifelong experience to mothers everyday lives profoundly changing their parenting role and transforming their view of mothering recognition of the experience of new mothering and mothers meaningmaking process stress coping mechanisms and resilience is critical to informing policies programs counseling and other therapeutic efforts to assist children with autism and their families for social workers in ethiopia and those working with the ethiopian diaspora in other regions of the world

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introduction nowadays the most widespread architectures belong to the domain of distributed systems 1 most of participants activities on these systems concern their data 2 using these systems implies some relationships with a lot of people these people may be partly unknown but one depends on them in several ways which personresource a user depends on to perform an activity whom can prevent a user from performing an activity which persons a user is able to avoid to perform an activity who is possibly able to access users data some of these questions raise several issues as someone may be able to grab information about who the user is what the user does and so forth that directly leads to privacy 3 trust 4 and security issues 5 the analysis of such systems is usually limited to technical aspects as latency qos functional performance failure management 6 etc the aforementioned questions give some orthogonal but complementary criteria to the classical approach currently people underestimate social dependences 789 generated by the systems they use and the resulting potential risks we argue that to be able to know dependences one should be aware of some key aspects of systems this paper proposes the sociopath metamodel this approach is based on notions coming from many fields ranging from computer science to sociology sociopath is a generic metamodel that considers two worlds the social world and the digital world sociopath allows us to draw a representation of a system that identifies persons hardware software and the ways they are related enriched with deduction rules sociopath analyzes the relations in the digital world to deduce the relations of dependences in the social world given an activity concerning some data as a modeling tool that bridges the gap between the digital and the social world sociopath can be useful in the evaluation process of a system with respect to security privacy risk and trust requirements the paper is organized as follows section 2 introduces the sociopath metamodel and gives a simple example of its use section 3 defines the way to compute the users digital and social dependences section 4 presents a brief overview of related works finally section 5 concludes and points out our ongoing work sociopath metamodel the sociopath metamodel describes the architecture of a system in terms of the components people use to access digital resources so that chains of dependences can be identified it distinguishes the social world where humans or organizations own physical resources and data and the digital world where instances of data are stored and processes run figure 1 shows the graphical representation of sociopath which we analyze in the following sections the social world the social world includes persons physical resources data and relations among them data represents an abstract notion that exists in the real life and does not necessarily imply a physical instance physical resource represents any hardware device person represents a generic notion that defines an individual like alice or a legal entity like microsoft the digital world the digital world has nodes that are defined as follows data instance represents a digital representation of data artifact represents an abstract notion that describes a running software this can be an application an operating system or a network service digital resource represents an artifact or a data instance actor represents a person in the social world or an artifact in the digital world the relations in sociopath several relations are drawn in sociopath in this section we briefly describe them owns this means ownership this relation only exists in the social world isconnectedto this means that two nodes are physically connected through a network for instance this symmetric relation exists only in the social world canoperate this means that an artifact is able to process communicate or interact with a target digital resource accesses this means that an actor can access a digital resource controls this means that an actor controls a digital or a physical resource there exists different kinds of control relations a legal entity who provides a resource controls its functionalities the persons who use this resource have some kind of control on it supports this means that the target node could never exist without the source node represents this is a relation between data and their instances in the digital world persons own some data in the social world data have a concrete existence in the digital world if they are represented by some data instance and supported by some physical resource as an actor in the digital world a person can access and control data instances representing her data this may be done through different resources thus implying some dependences on other persons moreover we consider that a person provides an artifact if this person owns data represented by a data instance which supports the artifact applying sociopath makes possible nontrivial deductions about relations among nodes for instance an actor may be able to access digital resources supported by different physical resources connected to each other figure 2 shows a basic sociopath model1 of a usecase on a unique pc in the social world a user john owns some data and a pc there are also legal entities as 3 using sociopath to derive dependences for an activity sociopath features a set of rules we can apply to underline and discover chains of accesses and controls relations table 2 shows the formal definitions of some rules that we can deduce from the metamodel basic definitions more details are given in 14 in this work we want to use these relations to better understand the social and digital dependences among entities in the model thus informally the sets of digital dependences of a person are composed by the artifacts a user passes through to reach a particular element the sets of social dependences are composed by the persons who control these a a ⊂ a a a ∈ a artifact f f artif act f f ⊂ f f f ∈ f digital resource dr dr resource dr dr ⊂ dr dr dr ∈ dr physical resource pr p r phyresource pr pr ⊂ pr p r p r ∈ pr data d d data d d ⊂ d d d ∈ d data instance di di datainstance di di ⊂ di di di ∈ di operating system o os operatingsystem o o ⊂ o os os ∈ o path γ σ path υ υ ⊂ γ σ σ ∈ γ activity w ω ω ∈ w set of activity restrictions s s p s s ∈ s activities and paths a user follows a path to perform an activity in a system some restrictions may be given to the ways the person might do their activity for instance if a person wants to read a doc document she must use an artifact that can understand this type of document so activity is defined as follows definition 1 we define an activity ω as a triple where p is a person d is data and s is a set of ordered multisets of f in a model so an activity ω is an element of p × d × s the sets in the s component of an activity are alternative sets of artifacts that are necessary for the person to perform her activity for instance the activity john edits totodoc is defined as ω we call paths the lists of actors and digital resources that describe the ways an actor may access a resource a person may perform an activity in different ways and using different intermediate digital resources each possibility can be described by a path definition 2 a path σ for an activity ω ∈ p × d × s is a list of actors and digital resources such that σ 1 p σ σ d represents ∀i ∈ 2 σ 1 artif act ∧ accesses ∃s ∈ s s ⊆ σ where σ i denotes the i th element of σ and σ the length of σ notation assuming that there is no ambiguity on the model under consideration the set of ωpaths where ω is noted υ ω and the set of all the paths in the model is noted υ in the first ωpath presented above msexcel is not mandatory to edit totodoc it appears in the ωpath because of the relation accesses between it and the artifact windows in order to exclude all the unnecessary elements from the ωpath so we define the minimal paths as follows definition 3 let υ ω be a set of paths for an activity ω a path σ ∈ υ ω is said to be minimal in υ ω iff there exists no path σ such that σ 1 σ 1 and σ σ σ σ ∀i ∈ 2 σ ∃j ∈ 2 σ σ i σ j notation the set of minimal paths enabling an activity ω is noted υ ω for sake of simplicity we name this set the ωminimal paths for instance for the activity ω john edits totodoc the set of the ωminimal paths are notation let say f ∈ σ iff ∃i such that σ i f and s ⊆ σ iff ∀f ∈ s f ∈ σ υ ω    john dependence we can now introduce the definitions of digital dependences and social dependences we say that a person depends on a set of artifacts for an activity ω if each element of this set belongs to one or more paths in the set of the ωminimal paths definition 4 let ω be an activity f be a set of artifacts and υ ω be the set of ωminimal paths p depends on f for an activity ω iff ∀f ∈ f ∃σ ∈ υ ω f ∈ σ for instance one of the sets on which john depends for the activity john edits totodoc is macos msword a person does not depend in the same way on all the sets of artifacts some sets may be avoidable ie the activity can be executed without them some sets are unavoidable ie the activity cannot be performed without them to distinguish the way a person depends on artifacts we define the degree of a persons dependence on a set of artifacts for an activity as the ratio of the ωminimal paths that contain these artifacts definition 5 let ω be an activity f be a set of artifacts and υ ω be the set of ωminimal paths and υ ω is the number of the minimal ωpaths the degree of dependence of p on f denoted d ω f is d ω f σ σ ∈ υ ω ∧ ∃f ∈ f f ∈ σ υ ω for instance the degree of dependence of john on the set macos msword for the activity john edits totodoc is equal to one while the degree of dependence of john on the set pages oowriter is equal to 23 from digital dependences we can deduce social dependences a person depends on a set of persons for an activity if the persons of this set control some of the artifacts the person depends on definition 6 let ω be an activity and p be a set of persons p depends on p for ω iff ∧ ∃f ⊂ f p depends on f for ω ∀f ∈ f ∃p ∈ p controls for instance one of the sets john depends on for the activity john edits totodoc is oracle apple the degree of a persons dependence on a set of persons for an activity is given by the ratio of the ωminimal paths that contain artifacts controlled by this set of persons definition 7 let ω be an activity p be a set of persons and υ ω be the ωminimal paths the degree of dependence of p on p noted d ω p is d ω p σ σ ∈ υ ω ∧ ∃p ∈ p ∃f ∈ σ controls υ ω for instance the degree of dependence of john on the set oracle apple for the activity john edits the totodoc is equal to 23 we recall that oracle controls oowriter and apple controls macos related work frameworks and tools modeling it systems are widely used in the context of enterprise architecture management 11 eam aims at giving a structured description of large it systems in terms of their business application information and technical layers with the additional goal of understanding how existing architectures andor applications should be changed to improve business or strategic goals sociopath rather focuses on dependence relationships although converging with these frameworks in some aspects for instance rmodp 12 is a generic set of standards and tools to create and manage aspectoriented models of systems rmodp analyzes and decomposes the systems in detail mainly focusing on standard compliance aiming at different goals sociopath gives a simpler overview of a system that is meant to inform the users about the relations that are implied by the system architecture without exposing technical details togaf 13 an approach for designing planning implementation and governance of an enterprise information architecture converges with sociopath in some of the concepts used to model the technical architecture of the enterprise unlike sociopath togaf focuses on several aspects of the software engineering process while describing the hardware software and network infrastructures none of these works considers dependence relations among users in the social world sociopath aims at improving awareness and exposing the relations of dependence generated on the social world from the digital world more details about the related works are available in 14 5 ongoing work and conclusion sociopath allows to deduce the degree of dependence of a person on the entities of a system architecture for an activity with sociopath it is possible to know for instance who can prevent a person to perform an activity or whom a person can avoid while performing an activity our ongoing work concerns several aspects currently sociopath does not distinguish the different kinds of access and control of an actor to a digital resource in order to consider intentions and expectations of users regarding digital resources sociopath can be enriched with access and control typologies to define different kinds of dependences moreover no difference is made between what persons can do and what they are allowed to do according to the law the moral rules etc we aim at distinguishing between dependences related to the systems architecture and dependences related to social commitments finally the results of sociopath can be related with the notion of trust of a person toward the persons she depends on indeed if a user does not trust some person she will be concerned about architectureinduced dependences on this person whereas if she trusts a person she will only be concerned about commitmentsrelated dependences

everyday people use more and more digital resources data application systems internet etc for all aspects of their life like financial management private exchanges collaborative work etc this leads to nonnegligible dependences on the digital distributed resources that reveal strong reliance at the social level users are often not aware of their real autonomy regarding the management of their digital resources people underestimate social dependences generated by the system they use and the resulting potential risks we argue that it is necessary to be aware of some key aspects of systems architectures to be able to know dependences this work proposes sociopath a generic metamodel to derive dependences generated by systems architectures it focuses on relations like access control ownership among different entities of the system digital resources hardware persons etc enriched with deduction rules and definitions sociopath reveals the dependence of a person on each entity in the system this metamodel can be useful to evaluate a system as a modeling tool that bridges the gap between the digital and the social worlds

18990_0

introduction as an important form of education vocational education is not only related to individual career development but also directly affects the economic prosperity and innovation ability of the society with the continuous development and change of social economy vocational education has gradually evolved from the traditional spare choice to an important way to cultivate practical skills and professional knowledge in vocational education students can gain knowledge skills and experience related to practical work preparing them for a smooth entry into the workplace although the importance of vocational education is gradually being recognized family prejudice and discrimination against vocational education still exist in china many families are more inclined to see academic education as a more valuable option while vocational education is often labeled as inferior at the same time some foreign countries highly recognize the status of vocational education providing students with a variety of career development opportunities 1 the purpose of this study is to deeply explore the prejudice and discrimination of chinese families against vocational education and to find the causes of these problems and the impact of these problems on individuals and society by comparing with foreign vocational education the prejudice and discrimination of chinese families towards vocational education family preference for academic education the influence of traditional values on vocational education chinese society has long held the traditional concept of attaching importance to academic education and families generally believe that the traditional academic path provides better opportunities for their childrens future development this preference often stems from parents expectations that their children will gain a higher social status and financial return by earning a higher degree as a result many families view vocational education with suspicion viewing it as a spare choice believing that students who choose vocational education seem to be forgoing a more promising academic path 2 discrimination in nontraditional occupations the influence of social perceptions on career choice another factor that influences the bias of chinese families towards vocational education is the social perception of discrimination against nontraditional professions in traditional social concepts certain professions are considered decent and status while others may be labeled as inferior this leads families to hold reserved or even negative views of some nontraditional occupations such as beauticians car repairmen waiters and so forth parents may object to choosing these occupations as a career direction for fear of the difficulties and social perception their children will face in these occupations reasons for the low status of vocational schools misconceptions about the quality of education and career prospects the relatively low status of vocational schools in china is partly due to widespread family skepticism about the quality of education in these schools some parents believe that the quality of education in vocational schools is not as good as that in regular schools and worry that their children will not acquire enough knowledge and skills here in addition parents may misunderstand the poor job prospects of vocational school graduates and prefer their children to choose the traditional academic path 3 recognition and development of foreign vocational education the system of foreign vocational education multiple choices and training opportunities compared with china many foreign countries highly recognize and attach importance to vocational education in these countries vocational education is regarded as one of the important ways to cultivate all kinds of talents and is widely respected as academic education the diversified vocational education systems in foreign countries cover a variety of skills training in different fields providing students with rich career options and development paths the diversity of such systems helps meet the interests and needs of different students enabling them to better develop their vocational skills 4 the balance between vocational and academic education the importance of cultivating diverse talents foreign vocational education systems usually emphasize the cultivation of vocational skills but also pay attention to the cultivation of students comprehensive quality and innovative ability compared with china more emphasis is placed on the balance between vocational education and academic education in foreign countries which is believed to help cultivate diversified and wellrounded talents the idea reflects an education philosophy that places equal emphasis on skills qualities enabling students to better adapt to the rapidly changing needs of society the role of vocational education in economic development providing support for social innovation and competition some foreign countries have realized that the role of vocational education in promoting social innovation and economic competitiveness cannot be ignored by cultivating qualified skilled personnel for all walks of life foreign countries can maintain the competitiveness of their industries and enhance their overall innovation capacity this is especially true in the fields of science and technology engineering medical care and so forth foreign vocational education graduates have contributed a lot to the scientific and technological innovation and development of society the influence of chinese family bias on vocational education limitations of career development the conflict between the pursuit of personal interests and family expectations the prejudice of chinese families towards vocational education often leads to limited personal career development many young people may be pressured by their families to pursue careers that are not in line with their interests and potential such choices that go against ones inner wishes may lead to career dissatisfaction and psychological stress affecting ones career achievements and quality of life at the same time it may also lead some people to lack motivation and enthusiasm in their work affecting their job performance and career development the talent shortage problem traditional skills and challenges facing the industry the bias of chinese families towards vocational education has also led to some traditional skills and industries facing talent shortages as society places more emphasis on academic education many young people choose to pursue academic knowledge while neglecting the study of traditional skills this has left some traditional industries and skilled positions facing a serious talent gap affecting the development and innovation ability of related industries 5 limited ability to innovate exclusion of nontraditional occupations affects social innovation and change the bias of chinese families towards vocational education may also limit social innovation and change innovation often comes from the intersection and collision of different fields and some neglected nontraditional careers may be the source of innovation however because these occupations are subject to prejudice and discrimination many individuals with innovative potential may be excluded from the innovation process thus limiting the possibilities for social innovation and change the prejudice and discrimination against vocational education in chinese families not only restricts the career development of individuals but also to a certain extent the development of the whole society the next section will explore strategies and suggestions to solve these problems with a view to promoting the development of vocational education and social progress in china 5 strategies and suggestions for solving them the importance of education the key to changing family attitudes in order to change the prejudice and discrimination of chinese families towards vocational education it is crucial to publicize education the government educational institutions as well as the media can join forces to convey the importance and value of vocational education to parents through publicity and education parents can realize that vocational education is also an important way to train talents and promote social progress so as to change their views on vocational education improve the vocational education system provide diversified training and development paths china should strive to improve its vocational education system to ensure its quality and diversity vocational education should cover a variety of skills training in different fields to meet the interests and needs of different students a wellrounded education philosophy that encourages personality development and the pursuit of interests fostering a wellrounded educational concept is the key to solving the problem of bias in vocational education education should pay attention to students individual differences and encourage them to choose a career path according to their interests and potential students should be encouraged to develop their own expertise in vocational education and be aware of the importance of different professions in society this will help reduce family and social discrimination and prejudice against specific professions 6 through the above strategies and suggestions china can gradually change the problem of family prejudice and discrimination against vocational education promote the development of vocational education provide more career development opportunities for individuals and provide strong support for social and economic growth and progress conclusion in this paper the author deeply discusses the prejudice and discrimination of chinese families to vocational education and analyzes its comparison with foreign vocational education through a comparative analysis the challenges faced by chinas vocational education as well as the advantages of foreign vocational education are clearly seen the prejudice and discrimination of chinese families towards vocational education is rooted in traditional concepts and social culture resulting in many young people giving up the choice of pursuing their interests and potential due to family expectations this phenomenon not only affects the career development of individuals but also hinders the innovation and progress of the whole society in contrast some foreign countries pay more attention to and recognize vocational education providing students with diversified training and development opportunities which is conducive to the overall growth of individuals and the development of society 7 through publicity and education that can gradually change the family concept and make parents realize that vocational education is equally important at the same time by improving the vocational education system we can provide students with more diversified development paths to meet different needs 8 finally fostering a wellrounded education concept will help reduce discrimination against nontraditional professions and promote the development of individual interests 9 we can gradually change the prejudice and discrimination against vocational education in families promote the development of vocational education and create a more favorable environment for individual career achievement and social progress 10 this is a daunting task but it is also a promising direction and we are confident that we can achieve the allround development of vocational education in china

this paper aims to explore the prejudice and discrimination of chinese families to vocational education and through the comparative analysis with foreign vocational education this research deeply explores the causes and effects of these problems through comprehensive literature analysis and case studies this paper argues that the prejudice and discrimination of chinese families to vocational education not only restricts the career development of individuals but also restricts the development of the whole society in contrast the recognition and emphasis on vocational education in some foreign countries provides more career development opportunities for individuals and provides strong support for social and economic growth in order to solve the problem of prejudice and discrimination of chinese families towards vocational education this paper puts forward some suggestions such as strengthening education publicity improving the vocational education system and cultivating the education concept of allrounded development aiming at promoting the development of chinas vocational education and social progress

18991_0

introduction happiness and other emotions have recently been an important focus of attention in a wide range of disciplines including psychology economics and neuroscience 1234 some of this work suggests that emotional states can be transferred directly from one individual to another via mimicry and the copying of emotionallyrelevant bodily actions like facial expressions 5 experiments have demonstrated that people can catch emotional states they observe in others over time frames ranging from seconds to months 67 and the possibility of emotional contagion between strangers even those in ephemeral contact has been documented by the effects of service with a smile on customer satisfaction and tipping 8 longitudinal data from facetoface social networks has established that emotions as diverse as happiness 9 loneliness 10 and depression 11 are correlated between sociallyconnected individuals and related work suggests that these correlations also exist online 412131415 however it is difficult to ascertain whether correlations in observational studies result from influencing the emotions of social contacts or from choosing social contacts with similar emotions 16 this problem has been addressed by using experimental methods to estimate network effects 171819202122 but these methods are either limited in scale and external validity or they require very close collaboration with private companies which means there are limited opportunities to conduct such experiments moreover even when companies are willing to conduct a largescale experiment they may have other goals that constrain its design for example they may wish to provide a uniform online experience to all users which reduces their willingness to create experimental treatment groups of sufficient size to take advantage of their massive scale here we propose an alternative method for detecting emotional contagion in massive social networks that is based on instrumental variables regression a technique pioneered in economics 23 in an experiment we would directly control each users emotional expression to see what impact it has on their friends emotional expression however since this is infeasible in our massivescale setting we identify a source of variation that directly affects the users emotional expression for this instrument we use rainfall importantly rainfall is unlikely to be causally affected by human emotional states so if we find a relationship it suggests that rainfall influences emotional expression and not vice versa we then measure whether or not the changes induced by the instrument predict changes in the friends emotional expression instead of changing the users emotion directly with an experimental treatment we let rainfall do the work for us by measuring how much the raininduced change in a users expression predicts changes in the users friends expression more formally suppose we can represent one persons emotional expression mathematically as follows y jt ht zf j zbx jt zc d jt s i a ijt y it ze jtð1þ this model assumes that emotional expression y jt by person j at time t is an additive linear function of other factors measured in the same time period including a timespecific factor h t an individualspecific factor f j the effect b of an exogenous factor x jt the effect c of an endogenous factor y it which is moderated by the strength of relationship a ijt between each friend i and person j at time t and by the degree d jt of person j and an error term e jt the key variable allowing us to estimate contagion in emotional expression is c and our inclusion of the individualfixed effect f j means that we are controlling for all possible characteristics of the person which further reduces the likelihood that correlation in emotions is driven by choice of social connections although this model seems straightforward to estimate it is not the reciprocal influence of a user on her friend and vice versa makes it difficult to interpret a simple association in their emotional states moreover in large populations it would be computationally expensive to apply the model to longitudinal content generated by millions of users with billions of friends over thousands of days we address the problem of computational cost by aggregating individuals into groups in the supporting information we show that when a subpopulation of individuals experience the same exogenous factor equation is equivalent to y gt ht zc g zbx gt zcy gt ze gtð2þ where for time t y gt is the average emotion of all people in subpopulation g h t and c g are time and subpopulation fixed effects x gt is the average exogenous factor for people in subpopulation g y gt is a weighted average emotional expression of friends of people in subpopulation g and e gt is an error term notice that we can use equation to estimate the social contagion effect c that appears in equation however y gt and y gt are still endogenous so prior to estimation we use an instrument x gt the aggregated rainfall of the friends of the people in subpopulation g to predict exogenous variation in the friends emotional expression y gt y gt h t zc g zb 1 x gt zb 2 x gt ze gt ð3þ consistent with standard recommendations regarding instrumental variable regression 23 we include in the first stage equation all other exogenous explanatory variables in the second stage equation thus we are estimating the effect of rainfall on average emotion while controlling for time and city fixed effects and for rainfall in all other cities this mitigates problems that may arise from autocorrelation in weather over time and between nearby cities we then use predicted values from equation to substitute for the value of y gt in equation to estimate the social contagion variable c this instrumental variables approach effectively addresses the problem of endogeneity 23 one worry in a model like this is that friends rainfall is correlated so the instrument might actually just be a proxy for the direct effect of rainfall on a persons emotional expression therefore to break any possible correlation between rainfall x gt in city g and the rainfall x gt of their friends we only consider how emotional expression is transmitted on days when it is not directly raining on city g then in a separate model we consider only days when it is raining in city g another worry is that there is an ecological fallacy in this model since we are using citylevel measures to estimate individuallevel effects in text s1 we mathematically formalize the relationship between the individual and aggregate level models to show there is no problem in our case but here we explain in words the ecological fallacy occurs when there are opposing effects of individuallevel and aggregatelevel variation for example robinson showed that us states with more immigrants had higher literacy rates even though immigrants were less likely to be literate 24 however a key factor that reduces the likelihood this is a problem in our model is that people in a city usually all experience the same weather on the same day so citylevel variation is a good predictor of individuallevel variation compare this to the robinson example where statelevel immigration rates are a very poor predictor of individuallevel immigrant status which allows for the possibility of opposite correlations with literacy at the aggregate and individual level we apply our method to data collected for a set of 1180 days on facebook from january 2009 to march 2012 the study was approved by and carried out under the guidelines of the institutional review board at the university of california san diego which waived the need for participant consent to protect participant confidentiality researchers did not personally view any names of users or words posted by users and all analysis of identified data took place in the same secure location on servers where facebook currently keeps users data users of facebook interact with each other in many ways mostly textual to measure emotional expression we use status updates which are undirected textbased messages that a users social contacts may view on their own news feed relying on the linguistic inquiry word count a widely used and validated word classification system 2526 we determine whether a post uses words that express positive or negative emotions although this is not the only way to measure sentiment 27 this method has previously been used to measure the emotional content of online messages 28 we then use two different metrics to quantify the average emotional state of a user during a day the fraction of posts expressing positive emotions and the fraction expressing negative emotions note that the positive and negative emotions are not two ends of the same scale some messages will express both positive and negative emotions just as individuals experience mixed emotions on occasion so it is possible to score high on both measures we then aggregate individual observations by city and day restricting our attention to all englishspeaking facebook users residing in the 100 most populous us cities results consistent with recentlypublished research on twitter posts 28 fig 1 shows temporal patterns of variation in positive and negative emotions on facebook that correspond to greater happiness on weekends and holidays fig 1 also shows geographic variation in emotion expression and illustrates the number of betweencity friendships in larger cities we matched these observations to publicly available meteorological records that indicate total precipitation for each day in each of these cities fig 2a shows results from the first stage regressions that estimate the effect of rainfall on a users emotion we find that an average rainy day decreases the number of positive posts by 119 and also increases the number of negative posts by 116 while these effects are small it is their statistical significance not size that matters since the goal is to use them as instruments to study the effect of exogenous variation in friends emotional expression on ones own expression both models generate test statistics that suggest the rainfall instruments are strong enough to provide adequate power and that they are also appropriately identified given widespread folk beliefs about the effect of mood on weather it is perhaps somewhat surprising that this relationship is contested past research has generally focused on small samples and researchers have argued that inconsistent results mean the effect of rainfall is contingent on season 29 or personality type 30 but the results here suggest that the reason for the inconsistent results may be due to lack of power another recent study of twitter data also uses weather variables to improve predictive power in a model of sentiment but the researchers do not separate the effect of rainfall from other weather variables 31 using predicted variation in emotional expression based on the exogenous effect of rainfall we can now estimate the total effect of a user on all her friends which is quantified by the contagion variable c fig 2b shows that each additional positive post yields an additional 175 positive posts amongst ones friends meanwhile each additional negative post yields 129 more negative posts by friends in other words the total effect of rainfall on emotional expression is about 150 larger than we would expect if we were only measuring the direct effect on users and ignoring the indirect effect on their friends and intriguingly although rain is the impetus for this contagion positive messages appear to be more contagious than negative fig 2b also shows that positive and negative emotional expressions tend to have an inhibitory effect on one another each additional positive post decreases the number of friends negative posts by 180 and each additional negative post decreases the number of friends positive posts by 126 again positive messages appear to have a stronger effect though here the difference is not significant and therefore may be due to chance we also evaluated these models when we restricted observations to rainy days and found that rainy days elsewhere have just as strong an effect in all cases regardless of the weather a person experiences directly our model allows us to measure the total direct effect of rainfall on the number of positive and negative posts in each city which is an increasing function of the number of users we can also measure the total indirect effect of rainfall in one city on users in other cities which is an increasing function of the number of users and their average number of friends in other cities but a decreasing function of the friends of those friends for example we estimate that a rainy day in new york city directly yields an additional 1500 negative posts by users in new york city and about 700 negative posts by their friends elsewhere fig 3 shows results like these for all 100 cities in our sample to evaluate the robustness of our method for estimating emotional contagion we created a placebo test of the effect of future weather and resulting emotional expression on todays emotional expression by friends in text s1 we show that none of our four models generates a significant estimate for contagion that travels backwards in time in future work it may be helpful to have greater resolution for the time of the exogenous factor to see how the effect of emotional contagion changes over hours or minutes moreover to exclude the possibility that the emotion contagion we measure is merely topic contagion between people writing posts about the weather we conducted additional tests that control for the frequency of weatherrelated posts in all cases the estimates for the social contagion effect c are substantially the same as in the original model suggesting that the results are not driven by topic contagion discussion our estimates of the social contagion of emotional expression suggest that there may be largescale spillovers in online networks what people feel and say in one place may spread to many parts of the globe on the very same day yet the 151 estimated ratio of the indirect to the direct effect is actually somewhat lower than other kinds of network effects measured experimentally for the spread of giving behavior in a public goods experiment for example it is estimated that each dollar given yielded two dollars in giving by others 32 for voting behavior a recent largescale experiment suggested the ratio is about four to one 17 while the method we elaborate here is potentially applicable to a wide variety of emotions and behaviors online an important limitation is that we cannot use this method to estimate contagion effects within subpopulations it is plausible that these effects might be even stronger when subpopulations are geographically defined since many studies suggest that physical proximity increases social influence between connected individuals 16 another limitation is that instruments are not always readily available and in some cases it may be unclear whether they are causally and directly related to the outcome variable of interest however when such instruments are indeed available this approach may prove to be a useful alternative to costly largescale experiments with limited external validity since they require neither experimental control nor alteration of the user environment although there are many factors that affect human emotions 333435 we have confirmed here that individual expression of emotions depends on what others in an individuals social network are expressing these results imply that emotions themselves might ripple through social networks to generate largescale synchrony that gives rise to clusters of happy and unhappy individuals and new technologies online may be increasing this synchrony by giving people more avenues to express themselves to a wider range of social contacts as a result we may see greater spikes in global emotion that could generate increased volatility in everything from political systems to financial markets 36 our results are also consistent with prior work on the evolutionary basis of human emotions and with prior work focusing on the fleeting direct spread of emotions in addition to their internal and psychological relevance 37 emotions play a specifically social role when humans experience emotions they do not generally keep them to themselves but rather they tend to show them like laughter and smiling 38 emotions expressed online may serve the evolutionarily adaptive purpose of enhancing social bonds human laughter for example is believed to have evolved from the play face expression seen in other primates in relaxed social situations 39 such facial expressions and positive emotions enhance social relations by producing analogous pleasurable feelings in others 16 by rewarding the efforts of others and by encouraging ongoing social contact given the organization of people into social groups larger than pairs 40 such spread in emotions probably served evolutionarily adaptive purposes in this regard it is noteworthy that during our study period users were increasingly expressing emotions as they adapted to facebook as a new communication environment our findings also have significance for public wellbeing to the extent that clinical or policy maneuvers increase the happiness of one person they may have cascade effects on others in their social networks thereby enhancing the efficacy and costeffectiveness of the intervention and these results suggest that such cascade effects may be promoted online for example providing better care for those who are suffering might not only improve their happiness but also the happiness of numerous others thereby further vindicating the benefits of medical care or public policy supporting information text s1 this document contains the detailed derivation of the model description of estimation techniques exposition of results and robustness tests

happiness and other emotions spread between people in direct contact but it is unclear whether massive online social networks also contribute to this spread here we elaborate a novel method for measuring the contagion of emotional expression with data from millions of facebook users we show that rainfall directly influences the emotional content of their status messages and it also affects the status messages of friends in other cities who are not experiencing rainfall for every one person affected directly rainfall alters the emotional expression of about one to two other people suggesting that online social networks may magnify the intensity of global emotional synchrony

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supporting choicesupport planning older people and managed personal budgets background currently english social care policy emphasises the personalisation of care and support the objective of personalisation is to give people choice and control by making the support they receive more tailored to individual needs preferences and aspirations personal budgets are promoted as the primary mechanism for this council progress in delivering pbs to all adult social care users is measured against a governmentset target the preferred approach is for pbs to be taken as cash direct payments under the control of individual service users this is assumed to offer greatest opportunities for choice and control over how the budget is used alternative arrangements are for the local council to manage the budget and use it to purchase councilcommissioned services on behalf of service users for a third party individual or organisationincluding service provider to hold the budget or a combination of these where the council or a third party manages the budget it is known as a managed personal budget where a service provider manages the budget under a council contract and agrees daytoday arrangements directly with the service user this is called an individual service fund older people have consistently been reluctant to take up the direct payment option the national evaluation of the individual budget pilot projects found older people significantly less likely to receive their ib as a cash direct payment compared with working age people with mental health problems or with physical disabilities older people were also less likely than other groups to report positive outcomes from ibs the subsequent implementation of pbs has shown similar patterns two national surveys of pb holders have collected data from volunteer councils and within these from selfselecting respondents and therefore risk being unrepresentative in particular respondents with personal budgets held as cash direct payments tend to be overrepresented nevertheless these surveys have found that older respondents are more likely than other user groups to have their budgets managed by the local council but less likely than other groups to report positive outcomes across a number of domains reanalysis of these survey findings to examine the specific experiences of older pb holders also found older people with direct payments reporting more positive outcomes than those with managed personal budgets older people are the largest group of adult social care users and their preferences for managed budgets are also reflected in overall pb trends although total numbers of pbs delivered by english councils continue to rise the largest increases are reported to have been in managed personal budgets the large proportion of older people opting for managed pbs combined with evidence of less positive outcomes associated with this option raise major questions about how far the benefits of personalisation in terms of creating opportunities for greater choice and control are available to a majority of older people older people also tend to be allocated smaller personal budgets than other user groups these are used mainly to purchase essential personal care the national ib evaluation found that older people were more likely than other users to report plans to use their budgets predominantly on personal care and domestic support and less likely to report plans for spending on leisure and recreational activities other studies have confirmed that older people are likely to spend most of their personal budgets on traditional social care services including home help personal care equipment cleaning and gardening before pbs were introduced frequent shortcomings in the flexibility and responsiveness of home care services received by older people were identified patmore and mcnulty found that flexibility in home care services depended on whether local authority purchasers encouraged responsive personcentred care francis and netten also found inflexible commissioning arrangements were barriers to responsive services to what extent therefore do managed pbs allow older people to receive individualised responsive home care support are increased opportunities for choice and control only available to those taking their budget as a cash direct payment how far are older people with managed pbs also able to enjoy the benefits of greater choice control and flexibility in the home care services they receive what opportunities do they have for personalisation so their home care support reflects individual preferences over for example the timing of visits the tasks undertaken or who carries them out these questions lead to a focus on the role of support planning in helping older people using managed pbs exercise choice and control it is argued that having information advice and support in planning how to use a personal budget is critically important in promoting personalisation and optimising the benefits of new opportunities for choice and control the most recent national personal budget survey found that for older people help with planning how to use the pb and feeling their views were included in the planning process were associated with the widest range of positive outcome indicators support planning includes informing older people about available service options and their costs helping to identify potential options and choosing between these it is therefore central to the exercise of choice on the part of personal budget holders how well prepared do support planners feel for this new role what opportunities and constraints do they experience and how do they respond to these although there were initially arguments for independent userled organisations to support users in planning how to spend pbs support planning is overwhelmingly carried out by or with help from council staff there is debate over how far council staff are embracing these new opportunities for innovation and shifting power towards service users the individual budget pilot projects found frontline social work staff split over whether support planning involved the erosion or enhancement of core social work values and skills most had hitherto practiced as care managers so training for their new roles was essential however this was reported to be variable and focused on principles rather than practice leaving frontline staff feeling unequipped moreover these principles may themselves generate new tensions lymbery draws attention to the difficulties of combining the core elements of personalisation that are compatible with underpinning social work principles and values alongside more neoliberal individualist discourses this paper examines support planners practice in facilitating choice and control by older people using managed pbs and in shaping demands on local home care providers it reports the experiences of frontline practitioners in local authorities and the managers of home care agencies in helping older people to plan their support and their views on the factors that help and hinder their respective support planning roles design and methods data is drawn from a wider study conducted between january 2011 and december 2012 of factors affecting the delivery of personalised home care services to older people opting for managed pbs rather than direct payments the study was conducted in three councils that all had large older populations large proportions of people using managed pbs and were known to have changed their commissioning andor delivery arrangements in order to increase choice for people using managed pbs two councils offered individual service funds or their equivalent in one council all older people opting for a managed pb were automatically given isfs in the second council this was only available through a few home care agencies however in neither council were pbs given to home care agencies to manage but remained as indicative allocations held by the council the study comprised 1 interviews with council commissioning managers about changes in commissioning and contracting for home care services and wider market development activities 2 focus groups with council support plannerscare managers about their experiences of support planning with older people using managed pbs to purchase home care 3 interviews with home care agency managers about their experiences of new commissioning and contract arrangements and their roles in helping older people plan how to use managed pbs 4 interviews with older people using managed pbs about their experiences and satisfaction this paper uses data from stages two and three in each study site one focus group was held with council support planners selected because they had extensive experience of helping older people plan the use of managed personal budgets altogether 19 council support planning practitioners participated in focus groups between november 2011 and march 2012 across the three councils 15 home care agency managers were also interviewed about their experiences of the changes introduced by the council and their roles in support planning managers were selected who were thought by their council to be offering more flexible services and to be sufficiently experienced with the new system to reflect on their experiences interviews took place between april and july 2012 all interviews and focus group discussions were digitally recorded and transcribed data analysis used the framework approach this involved writing summaries of data in cells on a spreadsheet to facilitate comparisons across themes and respondents ethical approval from social care research ethics committee and research governance from the study councils were obtained for this project support planning in routine practice formal support planning processes were similar in all three councils following assessment and an estimate of the amount of home care support required council support planners drew up a basic plan that included the number of visits needed each day ongoing needs any identified risks and individual preferences including preferred visit times and femalemale carers this basic plan was forwarded to councilemployed brokers whose role was to identify the most appropriate provider from all those with whom the council had a contract or framework agreement in the three councils framework agreements were gradually replacing block contracts which had previously allowed councils to purchase large volumes of home care services from providers who each covered a specific locality framework agreements set out the price and quality of services to be purchased by the council but unlike block or cost and volume contracts give no guarantee of the level of business where some block contracts remained these were given priority in allocating new clients brokers emailed requests for services including users preferences to all contracted providers home care agencies were expected to respond if they had capacity to provide the support requested if more than one agency could meet the request service users could choose between them once the user was allocated to an agency the agency added details to the basic council support plan for example specifying the duration and timing of visits the range of tasks to be carried out and the number of carers needed for each visit both council and agency staff were therefore involved in helping older people make choices council support planner experiences practice guidance recommends that support planning is undertaken in the knowledge of the level of the pb council support planners in the focus groups agreed that informing service users of the level of their pb and ensuring they understood the budget was theirs to use as they wished was important in empowering service users and facilitating choice however only in one of three councils were support planners routinely informed of the pb level before commencing support planning consistent with other research council support planners in the focus groups had all had some basic training relating to adult social care for example in safeguarding a number had also had training on personalisation but felt this was not sufficiently focused on their new support planning role one participant commented that her training materials had been adapted from a learning disability team and were inappropriate for older people a lack of appropriate role models was also perceived to be a constraint … theres not been this role before us … theres not been other support planners that we can look and say oh this is what you do thats what you do… theres noone to follow to say that is a role of a support planner … council staff reported that the support planning they now undertook with older people holding managed pbs was much less detailed than previously as detailed plans would be developed by home care agency staff however almost all focus group participants felt uncertain about exactly how userled the process should be some approached support planning with an idea of the specific agencies that were likely to provide services to the user and the ways those agencies operated in other words support planning was to some extent serviceled in contrast others focused solely on identifying the support that users wanted and made no assumptions about which agency might provide this … even if there was something that somebody needed or somebody wanted to enhance their life and it wasnt there i would push the boundaries to find it…and if there wasnt id try and use an agency… because ive built up good relationships and ask if they can create it … ive done that quite a few times … the latter approach appeared more userled and had the potential to require agencies to adapt and respond to individual user preferences all council focus group participants reported encouraging older service users to think creatively in identifying their service preferences they also reported discussing specific requests for example for malefemale carers preferred times of visits or particular activities where support was needed several support planners mentioned that older people tend to request services they are familiar with they try to change older peoples mindset by making them believe that they are the person whos in charge but that does not always work where older people made preferences they would be recorded and passed to brokers but support planners reported emphasising to service users that there were no guarantees these preferences would be met for example a service user who was an early riser might want a 6am visit and this would be stated on the support plan …that all sounds good at that stage when the service user will state what time they want the care package to be in place but by the time you do the four to six week review you will find that theres been so many different carers care workers ranging from it could be ranging from six oclock till twelve oclock in the afternoon for the first morning call support planners were also able to specify particular agencies that an older person or their family specifically wanted to use or avoid they agreed that in principle framework agreements generated an element of competitiveness which had the potential to improve the quality and responsiveness of home care support however in reality an overall lack of capacity in the contracted home care agencies restricted choice of providers leaving few options for service users in most cases especially in rural areas only one provider had capacity to respond to a specific request … realistically in each rural area theres probably three providers that are out there that the brokerage do go to but its whether or not they have got the service available at that particular time and they offer personal care council support planners therefore reported contacting home care providers directly in at least 50 per cent of cases to discuss users priorities and service needs once they had made informal arrangements with an agency they passed the case to a broker to formalise these some support planners felt this helped to identify appropriate providers more quickly although it involved lots of toing and froing council support planners thought that if brokers had more time for networking and a better knowledge of local home care agencies they would be able to work more creatively with providers ive had lots of bits and pieces go through that have been very successful but again thats been down to me doing the background work with the provider …ive done the ground work for them effectively council staff reported major challenges in combining their knowledge of the restricted capacity of local home care agencies with encouraging creative thinking on the part of older people some felt that encouraging service users to think outside the box was a bit of a waste of time they knew at the end of the day that brokers would have no particularly in the rural council meeting users preferences was additionally restricted by the costs and logistics of delivering care to remote localities one support planner explained that in the true sense of the world its not choice its about what is available in this council support planners argued for encouraging the development of smaller very local providers rather than relying on branches of large national chains they thought this would increase opportunities for personalisation and flexibility people needing two carers for each visit were reported to have even less choice of provider they had to accept whichever agency could provide two carers even if they had not wanted that particular provider even so the limited capacity of contracted providers could still create delays one person needing two carers was reported to have had to wait five months for his home care service to start council support planners across the three sites agreed that in reality choice and control was only available through the direct payment option indeed the restricted capacity of contracted home care agencies was reported to have pushed some service users into taking part of their pb as a direct payment so that they could spend it how they wished however support planners felt this did not necessarily mean service users had a choice because as one support planner put it they had to have a direct payment when they didnt want one home care agency support planning according to the interviews with home care agency managers detailed support plans were drawn up by senior managers team leaders or supervisors within the agency most of these staff were reported to have had basic training in for example moving and handling or dementia care but not all had support planningrelated training those who did had received training on topics such as care planning outcomesbased care assessments and personalisation one agency also ran an advocacy service which included help with support planning the manager of this agency felt the experience had helped staff learn the best ways to ask questions about the support people wanted staff in another agency were reported to have received training in personcentred care from a national organisation and used the organisations personcentred planning tools to help support planning some agencies that were branches of national or regional organisations had received inhouse training on personalisation overall the level and type of training appeared to be related to the structure enthusiasm and dynamism of the agency rather than the council managers and other agency staff involved in detailed support planning reported undertaking full risk and needs assessments and involving family members in discussions they described creating support plans which added detail to the basic plan received from the council a few agency managers reported referring service users to voluntary organisations that could offer some services at no cost and thus generate more scope for flexibility and creativity with the pb other managers reported telling older users about other services their agency offered in addition to personal care or about sources of frozen readymade meals to save agency time on meal preparation one manager described using a template at initial support planning visits to aid identification of individual preferences widen users knowledge of potential options and encourage them to consider and choose between these other mechanisms to encourage choice control and flexibility included detailed support plans that routinely encouraged low level choices for example requiring carers to offer a choice of meal rather than prepare a meal the ongoing roles of care workers as the eyes and ears of the agency as well as its organisational culture were believed to be essential in identifying changes in service users needs and aspirations the whole ethos of this organisation … is stop me and buy one right … most people go ooh what but stop me and buy one…… everything that has developed in this organisation particularly since 1990 has been around if you need it five might need it ten might need it so lets be flexible… you live your life the way you want by your by your choice and its part of the inculcated culture of the organisation to be like that so consequently we anything that were doing were encouraging and supporting the individual to choose what they want however agency managers thought one difficulty in trying to help older people to exercise choice and control over their support was that many wanted a predictable routine and therefore receive the same services at the same times each day older people dont always want to leave their homes… some of them are quite happy to stay in their own home where they feel safe where they feel secure where they know their limits… and they have the carers care workers coming in three or four times a day and that thats familiar thats what they know and they actually dont want to go outside of that … none of the agency managers interviewed mentioned any restrictions on the range of personal or domestic services they were willing to provide rather any such constraints were reported to be placed by the council on what services would be funded through pbs and what was specified in councils support plans thus most agency managers reported that they were not allowed to use pbs to take people out help with social activities provide sitting services or do shopping one agency manager reported they were able to do less for people now than they used to as resources for shopping cooking and cleaning had been taken out of pbs so you shut the door on em and youre only going in for a a bath or the medication change a pad the demand for those services is just as strong just as much as it is for having a bath and the medication you know the fact that they need the food in the house whos going to do it when theres no families there or youre putting the responsibility back up to on the family or do they go hungry talking about one client an agency manager observed …its very obvious he doesnt need what is being commissioned he needs support he doesnt need personalised care and he would benefit so much more from those hours being put to support he wants company he wants to go out he would benefit from somebody taking him to the pictures… and for some reason you cant do that you know … at the moment were fitting around the taskled commissioners needs rather than the clients needs agencies freedom to renegotiate support plans with service users varied between the three councils in the council where isfs were routinely offered to all older people opting for managed pbs agency managers all reported that during their initial support planning with new service users the duration and timing of visits were negotiated with the service user and did not need council approval changes in the content of support plansthe tasks undertakencould also be made without requiring council approval so long as these fell within the overall remit of council funding in contrast in the rural council which did not use isfs agency managers had to inform the council of any changes to the councils written support plan in the third council all changes to the times duration of visits or tasks undertaken had to be approved by the council one agency manager in this council explained that the times of visits were agreed between the agency and the council brokers if at the initial support planning visit from the agency the older person asked for visits at different times these new times had to be sent back to the council for approval in the same council another agency manager reported that her initial support planning visits were carried out jointly with a council social worker while this may have reduced any communication problems it removed opportunities for the agency manager to have an open dialogue with service users about what care the agency would provide the only reason i was there or i i was representing the agency is to put a face to the agency more than anything else and it wasnt for me to have an input as such… agency managers were asked about opportunities for time banking this enables any time saved from routine visits to be accumulated and used on a later occasion for example if family members happen to visit and help with personal care that time could be saved and used to take an older person out shopping managers reported that discussions about time banking typically arose at or between reviews not during their initial support planning visits in the council that routinely offered isfs agency managers reported the council had agreed that home care visits cancelled because of hospital admissions respite or holidays could be saved and used at a later date however this was a new policy so the manager interviewees had no experience of it yet in the second council an agency manager reported that their agency had developed and implemented a time banking scheme which the council had then approved however this flexibility did not appear to have been extended to other agencies in the council whose managers were interviewed in the third rural council time banking was not permitted one agency manager in this council thought time banking was unnecessary because any additional visits that were needed could be provided and the costs reclaimed retrospectively from the council however this approach appeared to overlook the principles of user choice and control on which pbs are based agency managers felt the amount of time they spent on support planning had increased with the introduction of pbs however they saw many benefits to detailed support planning being undertaken by them rather than by council staff one of the main perceived benefits was that agencies were involved with older service users over long periods of time and so could build up a bigger picture and relationships of trust moreover there were concerns that council support planning often took place when older people were unable to engage fully because they were in crisis very unwell or awaiting hospital discharge planning and reviewing support when an older person had settled back home and was feeling better was considered more appropriate for discussing preferences for the timing duration and content of visits agency managers also thought hearing about their support needs directly from older people themselves was important … its a good thing because you know were hearing it firsthand rather than second hand because quite often social workers get it wrong you know well go out to someone that a social workers done gone out there and done something and then theyll say oh i didnt say that i said this and its almost the same thing but its not managers were asked about the impact of the council brokerage systems on their delivery of personalised home care services again there were concerns about new communication barriers one perceived problem was that brokers gave very little time for agencies to respond to requests to deliver a new care package managers felt this gave them insufficient time to consider how the potential package of care might fit alongside existing workloads and clients another manager reported that she was sometimes not informed that her agency had been allocated a client consequently when care was due to start potential care workers had been allocated to other clients some managers particularly in the rural council preferred to discuss potential clients directly with council support planners as they felt the latter had a better understanding of service users needs and this helped them choose the most appropriate care workers ongoing service provisionresponding to changes council support planners considered regular reviews were important in ensuring service users changing needs and preferences continued to be met they reported encouraging service users to tell them if they were unhappy about any aspect of the home care service they received despite this intermediary role most service users were reported by council support planners to be reluctant to express dissatisfaction about the care they received i dont want to make waves i need her the care worker to come in just for me i need someone to come in to make sure im ok so please dont tell the agency council staff conducted reviews four to six weeks after the start of the home care service and thereafter annually in one council agency managers were expected to send the council a detailed support plan ten days after the home care service had started but a council support planner in that site reported that it could take agencies several months to do this in contrast agency managers in that site considered up to six weeks was needed for service users to settle into routines and any teething problems to be resolved where concerns were raised by a service user for example about agency carers not visiting at times specified in the detailed support plan or carrying out tasks as agreed council support planners would negotiate with the service user and agency to try and rectify the issue however sometimes delays in agency responses to service users concerns were reported to result in people putting up with unsatisfactory care for some time home care agencies conducted their own reviews two to six weeks after the service started to identify any teething problems and then at three six or 12 monthly intervals to identify any subsequent changes all agency managers reported relying on care workers to raise any concerns or requests between reviews typically any changes to support plans resulting from agency reviews needed council approval most agency managers thought the length of time to obtain such approvals hindered the delivery of flexible care discussion the study explored how far the benefits of personalisation in terms of creating opportunities for greater choice and control were available to older people using managed personal budgets to fund home care support in three councils this paper focuses on the role of support planning in local authorities and home care agencies in encouraging older people to exercise choice and control over their home care creating greater opportunities for choice and control by older people whose pbs are managed by local councils and used to fund home care services appears not to be straightforward resource constraints appear to be a major systemic problem undermining the effective functioning of new personalisation arrangements the low levels of older peoples pbs council restrictions on what pbs can be spent on and limited opportunities for time banking all imposed constraints on social care practice that in turn limited opportunities for empowering service users to exercise choice and control as lymbery concludes the potential of social work to offer a proactive and positive supporting role within the framework of personalisation is therefore being severely constrained nevertheless the study suggests that the new arrangements do have the potential to promote personalisation for older people opting for managed pbs and that more can be done to maximise this objective even within the current difficult financial situation the following aspects of these arrangements warrant attention first new council brokerage systems offer new opportunities for improving choice and efficiency in local care markets by facilitating the matching of individualised demand and supply however council brokers also risked creating new inefficiencies for social care practice by introducing new communication problems and delays the drawbacks and costs of these need addressing faster and more accurate communication between brokers council and agency support planners is needed under the new arrangements council support planners are less prescriptive about the details of support plans than was previous timeandtask based care management instead agency staff have greater responsibility to finetune support plans in the course of their initial discussions and longerterm relationships with users this shift of responsibility has the potential to increase older peoples control over their support arrangements offering more flexibility and responsiveness particularly as their needs and preferences change over time however there also appears to be some duplication of roles between council and agency support planners and confusion over their respective responsibilities greater clarity about respective roles may be needed so that agency staff are able to respond quickly to service users needs and preferences thus although isfs existed in two study sites these were not operating as anticipated other research has also found little evidence of isfs being used to their full potential there was no evidence at the time of this studys interviews with agency managers of agencies having delegated responsibility for managing the resources included in pbs even though they had delegated responsibilities for support planning requirements for agencies to obtain approval to relatively minor changes in support plans and blanket restrictions on the use of pbs for certain tasks like house cleaning limited opportunities for agency support planners to act more creatively in supporting service users to exercise choice such requirements also appear incompatible with the principles underpinning pbs to optimise the benefits of personalisation for managed pb holders service users may need much greater freedom to spend managed pbs as they wisheven within the confines of the smaller budgets allocated to most older people and providers may need more freedom to respond to users preferences and aspirations finally this study suggests that a lack of specialist training may be another barrier affecting the process of support planning for older people using managed pbs personalisation gives support planners new responsibilities in helping people to make choices support planners may need specialist skills to establish what matters to older service users how their support needs can best be translated into practical arrangements and a clear understanding of the mechanisms that can make personalisation work best for older people despite previous research on the challenges of personalisation for social work practitioners this study suggests that more attention may be needed to training that prepares practitioners for their current roles and practices most council support planners reported little change in how they worked with service users and were unsure about what their new roles expected of them councils may also need to consider the training needs of home care agency staff for their new support planning roles the limitations of the study the study is based on findings from three councils one of the benefits of recruiting only three councils as study sites was that we were able to get an indepth understanding of the contexts and processes within each site however we need to be cautious about generalizing from the findings although councils were selected that were known to be proactive in introducing changes to encourage personalised home care they may not be leading edge nor necessarily representative across england nevertheless the study offers insights into issues that are likely to be replicated elsewhere conclusions the findings suggest that new commissioning and brokerage arrangements have the potential to give older people using managed personal budgets greater choice and control over their support however resource constraints new communication barriers restrictions on the use of managed personal budgets and inadequate training for practitioners limited opportunities for support planners to act more creatively in helping older people to exercise choice ethics ethical approval for this project was given by the social care research ethics committee ref number 111ec080017

english policy emphasises personalised and flexible social care support using personal budgets pbs preferably as cash direct payments however most older people opt for their council to manage pbs on their behalf it is not clear what benefits of personalisation are available to this group of older people this paper reports research into the choices available to older people using managed pbs to fund home care services in three councils it focuses on the roles of support planners in councils and service provider agencies who are central to supporting choice on the part of service users data were collected from three focus groups with 19 council support planning practitioners and interviews with 15 managers of home care agencies  findings the study suggests that new commissioning and brokerage arrangements have the potential to give older people using managed pbs greater choice and control over their support however new communication barriers have also been introduced and some staff report receiving inadequate training for their new roles above all resource constraints were reported to impede council support planners in encouraging users to plan creatively how to use pbs resource constraints also meant councils placed constraints on how flexibly home care agencies could respond to changing needs and preferences of older users  applications the paper concludes by highlighting the implications of new arrangements for social work practice and some of the barriers that need to be addressed if the potential benefits of personalisation for older people holding managed pb are to be achieved

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introduction heart disease and stroke are among the leading causes of death in the usa 1 and yet there are substantial raceand placebased variations in heart disease and stroke mortality rates which have been partially attributed to various social structures and processes including residential segregation 2 3 4 williams and collins 5 proposed a correspondence sophia greer division for heart disease and stroke prevention centers for disease control and prevention 4770 buford hwy ne ms f72 atlanta ga 30341 usa the findings and conclusions of this report are those of the authors and do not necessarily represent the official position of the centers for disease control and prevention conceptual framework for understanding how residential segregationand associated spatial concentration of povertyacts as a fundamental determinant of population health williams and collins suggest that wideranging health patterns emerge as a result of the manner in which segregation spatially and socially patterns poverty economic and educational opportunity and social order or disorder metropolitan areas with high blackwhite residential segregation are characterized by isolation of black residents from quality schools employment and healthy environments when compared to white residents 5 6 7 8 9 10 as well as greater exposure to spatially concentrated poverty violent crime and related manifestations of social disorganization 11 segregation may therefore fundamentally influence raceplace variation in health outcomes such as heart disease and stroke mortality because of the associated health consequences of differential geographies of opportunity and distribution of exposures 512 specifically metropolitan segregation could racially pattern access to preventive health care healthful food environments green space and exposure to stress from discrimination disordered residential environments and fear of violence although the results of several studies have shown an association between racial residential segregation and cardiovascular health 9 13 14 15 few studies have explicitly tested the hypothesized contextual processes which may mediate this association in one study that did do so collins and williams 9 found that two socioeconomic factors substantially attenuated a positive association between segregation and heart disease mortality rates among black men this finding suggests that these factors may serve as pathways between segregation and heart disease mortality other study findings have shown variations in the relationship between segregation and cardiovascular diseases by age and race as well as variations by age race and place in the extent to which certain variables may mediate this relationship these findings suggest that further examination of suspected mediating factors is warranted 2315 williams and collins 5 examination of segregation as a fundamental cause of racial differences in health highlights the complexities of this construct segregation operates at multiple geographic levels and through multiple mechanisms that lead to living environments that are deleterious to health these environments often limit access to quality education job opportunities political power quality health care and social order using this model as a basis for our study design we attempted to determine the extent to which blackwhite residential segregation in metropolitan areas was associated with heart disease and stroke mortality rates as well as the extent to which these relationships were affected by ten variables proxying the countylevel economic social and healthcare environments methods study sample our study sample consisted of nonhispanic black and nonhispanic white residents of the 265 us metropolitan statistical areas with at least 5000 nonhispanic black residents in 2010 as defined by the us census bureau an msa is an area consisting of one or more counties with a core urban area of at least 50000 residents or a census bureaudefined urbanized area with a total population of at least 100000 residents the 265 msas in our study contained a total of 935 counties mortality data countylevel death records were obtained from the national center for health statistics national vital statistics surveillance system for the 2year time period january 1 2008december 31 2009 we abstracted data for nonhispanic white and nonhispanic black decedents aged 35 years or older whose underlying cause of death was heart disease or stroke as indicated by the following codes from the international classification of diseases 10th edition i00i09 i11 i13 or i20i51 or i60i69 to calculate ageadjusted death rates for heart disease and stroke we divided countylevel death counts by countylevel 2year nchs intercensal population estimates for 2008 and 2009 residential segregation racial residential segregation in each msa was based on the black isolation index 16 which reflects the populationweighted average proportion of black residents in all census tracts within each msa this index approximates the probability that two residents randomly selected out of a residential area are both black and can be used to indicate the extent to which black residents are isolated from white residents within an msa and the probability that a black resident will live in a predominantly black neighborhood the index ranges from 0 to 1 with higher values indicating greater racial residential segregation and thus a greater probability that blacks and whites are distributed in separate neighborhoods throughout the metropolitan environment census tracts were used as the subunit to calculate the isolation index for each msa we used the following equation to calculate the isolation index among blacks x p x ¼ x n i¼1 x i x ½ x i t i ½ where x i represents the number of blacks in a census tract i n represents the total number of census tracts within an msa x represents the total number of blacks in the msa and t i represents the total population of the census tract we will refer to the isolation index as segregation index countylevel pathway variables pathway variables represent areabased characteristics which describe access to education economic social employment safety and healthcare resources 5 6 7 8 9 10 11 we included the following variables as proxies percentage of adults without a high school diploma represented educational context percentage of individuals living in poverty percentage of adults who were unemployed and median household income represented economic context percentage of femaleheaded households and violent crime clearance rate represented social context percentage of residents without health insurance number of primary care physicians per 1000 population number of hospitals per 1000 population and preventable hospitalization rate represented healthcare context percentage of adults without a high school diploma percentage of uninsured adults and percentage of femaleheaded households were from the 2006 to 2010 american community survey 5year estimates poverty and median household income data were from the 2010 us census bureaus small area income and poverty estimates percentage of unemployed adults was from the 2010 bureau of labor statistics data violent crime clearance rates were from the 2008 uniform crime reporting program of the federal bureau of investigation via the interuniversity consortium for political and social research 17 number of primary care physicians and number of hospitals per 1000 population were from the 2008 area resource file preventable hospitalization rates were from the 20032007 dartmouth atlas of health care 18 statistical analysis we used poisson mixed effects models to examine the relationship between segregation and countyspecific heart disease or stroke death rates death rates and potential pathway variables were measured at the county level and the segregation index was measured at the msa level to account for correlation in countylevel characteristics among counties within the same msa and unmeasured msalevel sources of variation we included msa as a random effect in all models using the poisson mixed model we first calculated interquartile rate ratios and 95 confidence intervals of heart disease and stroke mortality rates for each of the potential pathway variables because preliminary regression models showed that age and race modified the relationship between the segregation index and mortality rates we stratified subsequent analyses by age group and race all rates were ageadjusted we used model 1 to assess the relationship between segregation and mortality rates while controlling for sex in subsequent models we added each potential pathway variable to determine its effect on this relationship we estimated mortality rate ratios for msas at the 75th percentile of segregation compared to those at the 25th percentile of segregation counties were excluded from the model if information was not available for a potential pathway variable this occurred in the case of models that included violent crime clearance rates and preventable hospitalization rates where 24 and 12 counties respectively were excluded results the distribution of the segregation index and potential pathway variables are shown in our results showed that all potential pathway variables were statistically significantly associated with both heart disease and stroke mortality rates except for number of primary care physicians per 1000 population and the violent crime clearance rate positive associations were observed for percent femaleheaded households percent less than high school education percent poverty percent unemployed percent uninsured hospitals per 1000 and preventable hospitalizations rate inverse associations were observed for median household income and crime clearance rate figures 1 through 4 summarize results from the poisson models stratified by race age and cause of death each figure shows rate ratios of heart disease or stroke death rates for residents of msas with segregation at the 75th percentile as compared to the 25th percentile controlling for gender alone and for each potential pathway variable in the model separately among blacks aged 3564 segregation was positively associated with both heart disease mortality rates 119 95 confidence interval 111 127 and stroke mortality rates however when we controlled for percentage of femaleheaded households the association between segregation and both heart disease and stroke death rates was attenuated such that both segregationmortality associations were no longer statistically significant controlling for percentage of adults in poverty and median household income also attenuated the association between segregation and stroke mortality rates among blacks aged 3564 years though by a smaller amount among blacks aged ≥65 years segregation was also positively associated with heart disease death rates however it was not associated with stroke death rates the relationship between segregation and heart disease death rates remained significant even after we adjusted for percentage of femaleheaded households among whites aged 3564 years segregation had a marginally significant relationship with heart disease death rates but was not associated with stroke death rates percentage of femaleheaded households and the preventable hospitalization rate most strongly attenuated the relationship between segregation and heart disease death rates in this group among whites aged ≥65 years segregation was positively associated with heart disease death rates but not with stroke death rates the association between segregation and heart disease death rates was attenuated to null when percentage femaleheaded households and preventable hospitalizations rate were added independently to the model discussion we found that segregation at the msa level was positively associated with heart disease mortality rates among blacks aged 35 or older and with stroke mortality rates among blacks aged 3564 among whites we found a marginally significant relationship between segregation and heart disease mortality rates among those aged 3564 and a positive association between segregation and heart disease mortality rates among those aged ≥65 years these statistically significant associations were most strongly attenuated by adjustment for percentage of femaleheaded households our findings concerning the relationship between msa racial residential segregation and heart disease death rates were mostly consistent with results from a previous study by collins and williams 9 which showed that segregation in 107 msas during 1990 was rates and introduces the possibility that segregation has an impact on both blacks and whites living in segregated environments our finding that adjustment for areabased percentage of femaleheaded households most strongly attenuated the association between segregation and both heart disease and stroke mortality rates reflects the complexity of the mechanism by which segregation is associated with heart disease and stroke mortality rates there are many theories by which this finding can be interpreted in this study we based our original hypotheses on the conceptual framework proposed by williams and collins 5 in which segregation is a multilevel construct that results in circumstances that perpetuate neighborhoods with high rates of femaleheaded households and high rates of poverty sampson also proposed a consistent theory by showing that the percentage of singleparent femaleheaded households in specified areas was positively associated with poverty rates male incarceration rates and the ratio of female residents to male residents in those areas 19 this cluster of community characteristics may be indicative of social disorganization which has been defined as the inability of communities to effectively enforce social norms achieve common goals and advocate for needed services 2021 concentrated social disadvantage and social disorganization have also been positively correlated with rates of property and violent crime 22 the stress of living in environments void of social support and with high levels of disorder has also been found to have a negative effect on biological processes associated with the cardiovascular health of all residents not just those with femaleheaded households 2324 in addition the propensity for local social disorganization has been found to increase in racially segregated metropolitan areas in which black residents reside relatively far from educational or economic opportunities 25 these findings in conjunction with our results showing that adjustment for femaleheaded household substantially attenuated the relationship between segregation and heart disease and stroke mortality rates suggest that the psychosocial and material environments produced by segregation are important contributors to geographic differences in these rates however these findings do not imply that femaleheaded households alone are the single pathway by which segregation operates poverty education employment and other neighborhood metrics are correlated with femaleheaded household rates and likely contribute to the concentration of high rates of femaleheaded households in certain neighborhoods 525 our finding that most of the potential pathway variables in our study had minimal or no effect on the relationship between segregation and heart disease or stroke death rates was unexpected because racial residential segregation is hypothesized to operate through the spatial distribution of economic educational and healthcarerelated resources 5 6 7 8 9 10 although this finding does not indicate that the remaining potential pathway variables are not important contributors to the relationship between segregation and cardiovascular mortality rates it may reflect that the mechanisms of these potential pathways are slightly different than femaleheaded households or these mechanisms are inadequately measured using census variables alone for example within school districts there can be heterogeneity in quality of education 26 because we used percentage of adults without a high school diploma as a proxy for educational context we were unable to assess school quality in addition this measure at the county scale may have masked variation in residents educational profiles at the neighborhood or other subcounty level thus limiting our ability to detect the possible effect of educational opportunity on the relationship between segregation and cardiovascular mortality rates the remaining variables representing potential pathways may similarly vary greatly within a county and differ substantially by race 27 results from previous studies have shown that the relationship between segregation and poor health outcomes is stronger among blacks than among whites our finding of an association between segregation and cardiovascular mortality rates among whites as well as among blacks suggests that the process of segregation could be associated with poorer health outcomes for both blacks and whites the differences in the strength of the association among whites by age warrants further investigation study limitations our study had two notable limitations first as noted previously because the study was cross sectional its results do not necessarily indicate causality second our results may have been affected by individualand neighborhoodlevel factors not accounted for in our models including access to healthy foods healthcare quality and opportunities for physical activity previous study results have shown substantial variation in residents access to food and alcohol stores physical activity opportunities and quality healthcare services at the neighborhood or other subcounty level 28 29 30 and these variations could be associated with both segregation and health outcomes also referred to as the modified area unit problem the use of data of different spatial scales can lead to different statistical inferences 31 conclusion this study makes several important contributions to our understanding of the impact of racial residential segregation on health outcomes it is the first study to systematically compare the associations by race and age group for both heart disease and stroke furthermore it is the first to examine a wide range of potential pathways and to identify social disorganization as a potentially strong pathway of the segregationheart disease and stroke mortality association by analyzing counties within msas we measure segregation at the scale of housing and labor markets 1132 while allowing for some degree of withinmsa variation in potential pathway variables and mortality this study highlights the importance of testing conceptual frameworks to understand the association between racial residential segregation and heart disease and stroke mortality our results suggest that racial residential segregation at the msa level may operate primarily through disruption of the social structure and social order however the results of this study also emphasize the importance of identifying which variables are most relevant as proxies for important processes through which racial residential segregation is associated with heart disease or stroke mortality future research should examine these intermediate pathways using both individual and aggregate data at multiple geographic scales to fully understand these placebased variations in cardiovascular outcomes this association among black men but not among black women however in contrast to our results their findings showed no significant relationship between segregation and heart disease mortality rates among white men or women the difference in these findings could be a result of the different time periods involved the difference in the age range of the two study populations or the greater number of msas in our study 9 we are not aware of any studies that have examined the association between msalevel racial residential segregation and stroke mortality rates despite the differences in results this study confirms the association between residential segregation and heart disease mortality

racial residential segregation has been associated with an increased risk for heart disease and stroke deaths however there has been little research into the role that candidate mediating pathways may play in the relationship between segregation and heart disease or stroke deaths in this study we examined the relationship between metropolitan statistical area msa level segregation and heart disease and stroke mortality rates by age and race and also estimated the effects of various educational economic social and healthcare indicators which we refer to as pathways on this relationship we used poisson mixed models to assess the relationship between the isolation index in 265 us msas and countylevel heart disease stroke mortality rates all models were stratified by race nonhispanic black nonhispanic white age group 3564 years ≥65 years and cause of death heart disease stroke we included each potential pathway in the model separately to evaluate its effect on the segregationmortality association among blacks segregation was positively associated with heart disease mortality rates in both age groups but only with stroke mortality rates in the older age group among whites segregation was marginally associated with heart disease mortality rates in the younger age group and was positively associated with heart disease mortality rates in the older age group three of the potential pathways we explored attenuated relationships between segregation and mortality rates among both blacks and whites percentage of femaleheaded households percentage of residents living in poverty and median household income because the percentage of femaleheaded households can be seen as a proxy for the extent of social disorganization our finding that it has the greatest attenuating effect on the relationship between racial segregation and heart disease and stroke mortality rates suggests that social disorganization may play a strong role in the elevated rates of heart disease and stroke found in racially segregated metropolitan areas

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investigating social deprivation and comorbid mental health diagnosis as predictors of treatment access among patients with an opioid use disorder using substance use services a prospective cohort study emma a adams 1 justin c yang 23 amy odonnell 1 sarah minot 3 david osborn 23 and james b kirkbride 2 background in 2020 there were an estimated 613 million people globally who used opioids in the past year 1 opioid use and related deaths are leading to some countries experiencing opioid epidemics 23 an estimated 12 million people are expected to die from opioids by 2029 in canada and the usa 2 the rise in deaths from opioids in canada and the usa over the past ten years can be linked to synthetic opioids including illicit opioids as well as misuse of licit substances 45 but these have been less commonly used or prescribed in england 6 between 2016 and 2017 there were an estimated 261294 individuals aged 15 to 64 who used opioids in england 74 per thousand of the population 7 rates of opioid use vary across england with more deprived regions experiencing greater prevalence compared with less deprived areas 7 social deprivation is also strongly associated with risk of several psychiatric disorders including psychotic disorders 89 raising the possibility that the cooccurrence of substance use disorders and mental health disorders in the same individuals share a common aetiology this possibility is reflected in estimates of comorbid opioid use and mental health diagnoses for example in england approximately 57 of people accessing opioid misuse treatment selfreport a comorbid mental health treatment need 7 this is consistent with estimates from north american studies which found rates of comorbid mental health ranged from 45 to 80 among patients seeking buprenorphine or methadone treatment for opioid dependence 10 11 12 13 14 opioid treatment can take place within the community primary care secondary care or residential settings in the form of structured prescribing and or psychosocial interventions 7 nonetheless treatment effectiveness in the community is lower than efficacy report in randomised controlled trials for example abstinence rates after three and six months of treatment in england are nearly 20 lower 15 than average abstinence rates found in rcts for opioid substitution treatment 16 evidence suggests that several factors contribute to poor treatment outcomes in realworld settings including relapse drop out from treatment and death 15 existing mental health disorders may also affect outcomes following treatment although evidence is mixed 121317 in addition exposure to deprivation may also affect ongoing engagement with treatment the limited previous research investigating social deprivation as a predictor of opioid misuse have tended to focus on prescribing use access to support and patient profiles for opioid use 1115 18 19 20 21 other important outcomes such as subsequent substance use service engagement which may indicate ongoing treatment or rates of subsequent crisis or inpatient care use which may indicate relapse have not been investigated to date in comparison to rcts routine electronic health record data present an opportunity to investigate differences in realworld treatment outcomes within entire healthcare systems rather than in controlled experimental conditions here we used ehr data from a secondary mental health care service provider in innerlondon to investigate the association between social deprivation and comorbid mental health diagnoses and subsequent contact with substance use crisis or inpatient services in patients diagnosed with opioidrelated disorders between september 2015 and may 2020 as a secondary outcome we investigated the association between social deprivation and comorbid mental health diagnoses and time to accessing crisis and inpatient services we hypothesised that social deprivation would be negatively associated with accessing services while comorbid mental health diagnoses would be positively associated with accessing services further we hypothesized that multiple comorbid mental health diagnoses would show greater magnitudes of associations methods data source we constructed a cohort of participants treated for a first episode of opioidrelated disorder in the camden islington national health service foundation trust c i is part of the publicly funded healthcare system which provides free secondary mental health services for a catchment area of approximately 470000 residents within the two innercity london boroughs of camden and islington secondary mental health services are a referralbased system where people would normally access treatment to stabilise their mental health or substance use needs after a point where support in their community or primary care is insufficient to meet their current needs once someone has been discharged from secondary mental health services they should be able to get appropriate support in their community or primary care settings ehr data were made available via a database known as the clinical record interactive search system 22 cris contains anonymised full clinical records and notes in both structured fields and interrogable unstructured clinical freetext of all contacts with c i for over 160000 mental health service users from 2009 onwards sample we included c i patients residing in the london boroughs of camden and islington with a first episode of care with a substance use service between september 1 2015 and may 31 2020 with a recorded f11 diagnosis information was not available on whether people were using illicit or licit opioids we excluded patients with a recorded diagnosis for an organic disorder or who were not residing in camden or islington we followed patients for up to one year after discharge from their first episode of care with a substance use service substance use services included any drug service offered through c i which could involve onetoone key working day programmes testing and treatment assessments residential detoxification and rehabilitation centres measures outcomes our two primary outcomes were rates of reengagement with c i substance use services and rates of contact with c i inpatientcrisis settings for each patient we recorded the total count of these outcomes over the oneyear followup period following discharge from initial treatment to estimate rates we were unable to explore reason for discharge from the original substance use encounter and as such are unable to determine if reengagement with substance use services was a good or negative outcome engagement with crisis services could be seen as a negative outcome our secondary outcome was time to first contact with c i crisis or inpatient settings these included any acute mental health care settings where urgent medical treatment is sought and services specifically designed to provide acute mental health crisis support such as crisis houses and crisis outreach teams exposures social deprivation was measured using the index of multiple deprivation for england 23 a composite measure of multiple deprivation for small areas based on 37 indicators across 7 domains patients were geocoded to the lower super output area of their last recorded place of residence and linked to their imd tertile relative to all lsoa within the catchment area lsoa information was missing for 178 of our study sample whom we chose to retain as a separate category since we reasoned that a substantial proportion of participants with an opioidrelated disorder may have been of no fixed abode at the point of care we defined comorbid mental health diagnosis at baseline as a recorded icd10 psychiatric diagnosis prior to or within 30 days of the start of their first episode of care with substance use services this approach minimised misclassifying psychiatric diagnoses arising subsequent to the substance use disorder but provided time for followup psychiatric assessments to be made immediately after first contact we initially classified participants as having any of the following comorbid mental and substance use conditions other substance use common mental disorders severe mental illnesses personality disorders and other mental health conditions from this we classified participants into four mutually exclusive categories no comorbid diagnoses diagnosis in one of these broad sets of psychiatric disorders diagnosis of a nonopioid substance use disorder and diagnoses in two or more of these broad sets of comorbid substance use or psychiatric conditions confounders we extracted ehr data on sex age ethnicity and marital status as potential confounders we also included two additional arealevel measures and social fragmentation index based on patients lsoa data for social fragmentation and population density were estimated using 2011 census data 24 and grouped into tertiles consistent with previous studies 2526 we estimated social fragmentation as the proportion of unmarried persons people living at a different address 1 year ago people living alone and people privately renting these data were combined into a single index by summing zscores for each indicator analysis we used fishers exact tests to examine differences in the distribution of categorical exposure and confounder variables between those with and without subsequent mental health service use engagement and mannwhitney tests for corresponding continuous variables for our primary outcomes we used negative binomial regression models to compare rates of reengagementcontact with substance use services and crisisinpatient settings respectively for our secondary outcome we used cox proportional hazards regression to model time to first contact with crisis or inpatient settings and undertook a test of the proportional hazards assumption cohort entry was the date of discharge from first episode of care with a substance use service and date of exit was first engagement with a crisisinpatient service death or censorship after 365 days we presented incidence rate ratios and hazard ratios for our primary and secondary analyses respectively alongside 95 confidence intervals for all analyses we presented univariable bivariable and multivariable results data were analysed using r 431 27 some small cell data has been supressed to maintain anonymity suppression of these cells is a requirement of the ethical approval for research use of this nhs database and is aligned with guidance from ons and nhs on statistical disclosure control the study was approved by the research database oversight committee with ethical approval for epidemiological research granted by the east of england cambridge central research ethics committee results sample characteristics we identified a total of 517 patients who had a first episode of care with substance use services in camden and islington nhs foundation trust between 2015 and 2020 of this sample 259 patients reengaged with a substance use service over the following 12 months and 63 patients had contact with crisis or inpatient settings those who reengaged with substance use services had a lower median age than those who did not there were differences in marital status although likely associated with the higher rates of no recordeddisclosed marital status for those who did not reengage with services there were no further differences between those who did and did not reengage with services we observed differences in comorbidity between those who had and did not have contact with crisis or inpatient settings such that those who did not have contact with crisisinpatient services were more likely to have no recorded mental health comorbidity compared to those who had contact with crisisinpatient services there were no statistically significant differences between the two groups there were no differences in gender between the two groups rates of reengagement with substance use services in this specific sample we found social deprivation was not associated with rates of reengagement with substance use services during followup in our fullyadjusted models there was no evidence that any comorbid mental health or other substance use diagnosis were associated with rates of reengagement with substance use services during followup despite some initial evidence that those with an additional nonopioid substance use diagnosis had higher rates of reengagement in unadjusted and bivariate models additional file a provides the full set of regression coefficients from these models rates of contact with crisisinpatient services we found no evidence that social deprivation was associated with contact rates with crisisinpatient services in fully adjusted models in fully adjusted models any comorbid mental health or other substance use diagnosis was associated with increased rates of contact with crisisinpatient settings those with multiple comorbid mental health diagnoses had the highest rates of contact with crisisinpatient services relative to those without comorbidity rates of contact with crisis inpatient services were also higher among those with only one comorbid mental health disorder and those with a nonopioid substance use disorder additional file b provides the full set of regression coefficients from these models time to first contact with crisisinpatient services we found no evidence that social deprivation was associated with time to first contact with crisisinpatient services in contrast and consistent with rates of crisisinpatient use above participants with a comorbid nonopioid substance use disorder or with a single or multiple comorbid mental health diagnoses at baseline had shorter time to first contact with crisis inpatient services all models additional file c provides the full set of regression coefficients from these models discussion to our knowledge this is the first study to use routinelycollected ehrs to investigate social deprivation and comorbid mental health diagnosis as predictors of reengagementcontact with statutory substance use services crisis or inpatient settings amongst patients with a diagnosis of opioid use disorder diagnosis following their first episode of treatment our study found social deprivation did not influence rates of reengagement to substance use services up to one year after diagnosis or rates of contact with crisisinpatient service use in this period our study extends previous knowledge by finding large and robust increases in the rate of contact with crisis inpatient services as well as a shorter time to first contact with crisis services in those with one or more comorbid psychiatric disorders and comorbid nonopioid use substance use disorders at the time of their first episode of care with substance use services this suggests despite prior evidence demonstrating associations between comorbid mental health diagnoses and access to services clinical pathways have perhaps not been adapted sufficiently to address these concerns meaning of the findings many studies find increased opioid prescribing in more deprived areas 19 28 29 30 suggesting a link between opioid use and deprivation our findings by contrast suggest that deprivation may not be associated with reengagement with secondary mental health substance use services for people with an opioid use disorder diagnosis one possible explanation is that our catchment area of innerlondon is more deprived on average than the remainder of england further nearly 60 of participants with a substance use disorder in our study lived in the most deprived areas of camden and islington or were missing a residential address possibly due to homelessness which is associated with nonmedical use of opioids 3132 thus the absence of differences in rates of service reengagement and contact by deprivation level in this sample may be due to a floor effect since most of our sample were already living in very deprived circumstances over 50 of our cohort had at least one recorded comorbid mental health or substance use diagnosis alongside their opioid use disorder diagnosis at first contact this proportion is inkeeping with the published evidence 10 11 12 13 14 our findings strongly demonstrated that these comorbidities increased rates of contact with crisisinpatient settings in secondary mental health care for people with an opioid use disorder results from a large globally representative crosssectional household survey of individuals using opioids found that the presence of at least one comorbid mental health condition doubled the odds of accessing substance use disorder treatment 33 this aligns with our findings around higher rates and shorter time to contact with crisisinpatient care in the first 12 months after initial treatment that study 33 however did not differentiate between having one or multiple comorbid mental health diagnoses here we extend the literature to show that people with multiple comorbid mental health diagnoses had the highest rates of contact with crisis and inpatient settings compared with those without any comorbidity rates were also high for those with one comorbid mental health or substance use diagnosis and those with single or multiple mental health comorbidities had the shortest time to crisisinpatient contact during followup limitations we used routine data in a secondary mental health care system for a defined catchment area to provide insights into longitudinal predictors of treatment usage for people with an opioid use disorder diagnosis using realworld data allowed us to understand the impact of comorbid mental and substance use disorders as well as deprivation on longitudinal use of clinical mental health services our study also has several limitations ehr data were primarily collected for clinical purposes due to changes in the electronic health care provider contracted by c i substance use diagnoses entered in structured fields were not available prior to august 2015 which restricted the case ascertainment period in our study design even though cris records began in 2009 furthermore some cells in descriptive tables were suppressed to preserve patient privacy and confidentiality we acknowledge that this limits the ability to ascertain whether or not there were sufficient numbers among groups where counts have been censored as the end of our study period overlapped with the start of the global covid19 pandemic decreased engagement and contact with health care services could be partially attributable to reductions in service provision and wider alterations to normal health care provision 34 one further limitation of cris data is that residential address information was based on the latest clinical record with historical addresses overwritten by more recent ones this means that we may have misclassified exposure to deprivation amongst any patients who moved between lsoa or became homeless during their care with c i we were unable to assess the extent of this bias in our study but we cannot exclude reverse causality as an explanation of our results with respect to deprivation people with opioid use disorders may also be a highly mobile and transient population which may have led to misclassification of their social deprivation exposure further we did not have information on cohort exit so were unable to take this into account missing data was an issue on some information something which is inherent to most electronic health records although we have discussed missingness in lsoa data in terms of homelessness we cannot exclude the possibility that data were missing for other reasons the generalisability of our findings more broadly should be considered this study only reported on individuals with an opioid use disorder diagnosis who were accessing substance use services through statutory secondary mental health care services our results may not generalise to those who solely accessed substance use treatment in their community or through private or third sector organisations or who had yet to seek any treatment further socioeconomic inequalities in support might be masked by the fact that wealthier people may be more likely to access nonnhsprivate treatment and support additionally we did not have information on the nature of opioid misuse within our cohort by virtue of using routine clinical data only mental health data on recorded clinical mental health diagnoses is available which may be an underrepresentation of actual mental health need the catchment area of camden and islington is also a very densely populated innercity area of london with high levels of deprivation our findings may not generalise to other regions of england or elsewhere interactions were not investigated in this analysis an a priori assumption based on clinical expertise was made that the estimates are valid across all subpopulations however we acknowledge that this might not be the case implications for policy practice and research our findings suggest a need to identify comorbid mental health and substance use issues at the first point of treatment in secondary mental health care settings and provide appropriate signposting and support to try to reduce the amount of reliance on readmission to the secondary mental health care system although due to the size of the sample we were unable to separate by separate psychiatric conditions previous research has shown certain psychiatric conditions have been found to be more strongly associated with continued opioid use and decreased treatment retention 1335 this has implications on care planning and treatment design for patients with complex needs who are at greater risk of poor treatment outcomes interventions and support offered through substance use services could benefit from introducing broader psychiatric and substance use screening and targeting interventions around wider social financial and health care needs to ensure individuals are better supported with their additional needs 36 particularly among those presenting with multiple mental health and substance use conditions conclusion we found that any comorbid mental health condition including another substance use disorder was associated with increased rates of contact with crisisinpatient services among patients within one year of contact with substance use services by contrast no association was found between such comorbidities and reengagement with substance use services time to first crisisinpatient care was at least three times shorter for people with an opioid use disorder diagnosis with a comorbid mental health condition compared with those without another mental health condition or substance use disorder we did not observe an association between arealevel deprivation and reengagementcontact with services for individuals with an opioid use disorder diagnosis given the common cooccurrence of mental health and substance use disorders among those with an opioid use disorder diagnosis further observational and interventional work is needed to better understand the needs of this group allowing them to be better supported in their treatment journeys future research should work with people who have lived experience of opioid use to investigate and explore different treatment outcomes potentially including those accessing services outside of statutory care data availability data are owned and controlled by camden islington nhs foundation trust these data are not publicly available in the interest of patient confidentiality and may only be accessed by approved researchers from within a secure firewall in the same manner as the authors for more information please contact abbreviations competing interests the authors declare no competing interests

background opioid use is a major public health concern across the globe opioid use and subsequent access to care is often shaped by cooccurring issues faced by people using opioids such as deprivation mental illhealth and other forms of substance use we investigated the role of social deprivation and comorbid mental health diagnoses in predicting reengagement with substance use services or contact with crisis and inpatient services for individuals with opioid use disorder in secondary mental health care in innercity londonwe conducted a prospective cohort study which followed individuals diagnosed with a first episode of opioid use disorder who accessed substance use services between september 2015 and may 2020 for up to 12 months using anonymised electronic health records we employed negative binominal regression and cox proportional survival analyses to assess associations between exposures and outcomescomorbid mental health diagnoses were associated with higher contact rates with crisisinpatient services among people with opioid use disorder incidence rate ratios irr and 95 confidence intervals ci were 391 174914 for nonopioid substance use comorbidity 892 181644 for a single comorbid mental health diagnosis and 159 589475 for multiple comorbid mental health diagnoses social deprivation was not associated with contact rates with crisisinpatient services within this sample similar patterns were found with time to first crisisinpatient contact social deprivation and comorbid mental health diagnoses were not associated with reengagement with substance use servicescomorbid substance and mental health difficulties amongst people with an opioid use disorder led to earlier and more frequent contact with crisisinpatient mental health services during the first 12 months of follow up given the common cooccurrence of mental health and substance use disorders among those who use opioids a better understanding of their wider needs such as social financial and other nonmedical concerns will ensure they are supported in their treatment journeys

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introduction one of the conflicts that have shaken the region the most and negatively affected the level of life in the south caucasus where russia has always been a hotbed of conflict for centuries is the nagornokarabakh conflict which started and continues for more than 30 years between azerbaijan and armenia nagornokarabakh is in the southern caucasus between azerbaijan and armenia which is a landlocked area in transcaucasia located in karabakh a geographic area lying between zangezur and lower karabakh and covering the lesser caucasus mountains karabakh is mostly a mountainous region extending from eastern armenia to southwestern azerbaijan and covers approximately 4400 square kilometers with the entire area located at an average elevation of 1100 meters above sea level many narratives and interpretations have been created about the karabakh conflict which has been going on between armenia and azerbaijan for about 28 years with more than 30 thousand casualties and hundreds of thousands of refugees however most of these discourses approach the events from a political point of view undoubtedly women are among the most affected ones in the karabakh war because the loss of a breadwinner in the family in patriarchal culture discouraged them from building a career and there is no official assessment of the situation in terms of women who are directly or indirectly affected by the conflict in the region it is essential to reveal the difficulties of conflictaffected women and what should be done from the perspectives of women therefore the main purpose is to understand the karabakh conflict from the views of conflictaffected women by the consequences of the wars between 19881994 and 20162021 furthermore this research seeks to explore what rural women think about the conflict and its resolution inclusive and sustainable peacebuilding requires the voices of women to be heard and it is important to know the womens perspectives to prepare populations for peace so far the negotiations on the nagornokarabakh conflict have been conducted by politicians and local communities especially the women have been excluded from the official peacebuilding process one of the interviewees mentioned that «every time when the ministers of foreign affairs or the presidents came together we rural people were thinking that they would meet and have a great lunch together then finish and nothing else the politicians dont care what we want or we need» as one of the most directly affected groups by the nagorno karabakh war most women have hope and desire that all these ends in a peaceful way locals are very upset about what happened and may continue to happen at any moment especially the ones who lost their relatives or family members in this war are the most affected ones the fatalities that have taken place and continue to happen are not often framed in the context of the local peoples opinions but only in the political attitudes of the central governments involved and especially women are excluded from the peacebuilding and peacekeeping process since the peace efforts conducted by politicians have failed without any progress and the armed conflict was renewed on september 27 2020 it is obvious that the peacebuilding process should continue through including both communities at the grassroots level especially women of both nations to be involved in the peace process and they must participate actively to find ways for ending this conflict from this point of view this research will explore how these rural women see the process and what they think about peacebuilding and peacekeeping this study gives an opportunity to reveal the true thoughts of the women living in the rural area barda and how the conflict can be resolved according to them by documenting these perspectives i will demonstrate how the local and central governments should pay attention to the opinions of the conflictaffected women in the study theoretical information was given with an overview of the history of the karabakh conflict and in the implementation part indepth interviews which is a technique of qualitative research method were conducted with 10 rural women who witnessed the war directly or indirectly in the findings a general overview has been presented the brief history of the nagornokarabakh conflict the beginning of the history of the karabakh conflict coincides with the collapse of the russian empire in 1917 in the present nagornokarabakh territory most of the population who considered themselves armenians settled they lived as a community in the lands claimed by both states azerbaijan and armenia under the armenian name but when both states lost at the time of the bolsheviks violation in 1920 the karabakh issue remained unresolved known as the one who divided the nations stalin was given the rule of azerbaijan when the three major states of the region azerbaijan armenia and georgia were reestablished as the soviet union republics in 1930 in 1987 the new chairman of the communist party mikhail gorbachev defended the claim that the nagornokarabakh autonomous province was taken from the azerbaijan ssr and given to the armenian ssr the new policy regarding karabakh was to fuel the fire although dating back to the beginning of the twentieth century it coincides with the year 1988 that is considered the start of the conflict when the conflict became more comprehensive and expanded according to de waal february 1988 is generally accepted as the start date of the modern karabakh debate between armenia and azerbaijan however the first violent incidents violence against the armenians in the chardahli village of azerbaijan and against the azerbaijanis in the provinces of mehri and gafan in the south of armenia took place a few months ago not in karabakh but in armenia and azerbaijan thus the events began to grow more and more and the armenians began to move towards nagornokarabakh demands for the unification of armenia led to the start of the first karabakh war according to vicken cheterian at the heart of the nagornokarabakh problem is the status problem this is due to the dual identity of this region since the 1920s for the ussr nagornokarabakh was both armenian and azeri it was armenian because the nagornokarabakh autonomous region a local autonomy as the soviets understood it was created because most of the population was ethnic armenians both the armenian population and the local armenian party elite of nagornokarabakh were dissatisfied with the arrangement and felt discriminated against they saw the solution to their problems by leaving soviet azerbaijan and joining neighboring soviet armenia within the logic of the soviet government they raised the issue of changing the status of nagornokarabakh we now know that this led to the death of thousands the displacement of hundreds of thousands the destruction of entire communities and a major confrontation that led to unresolved conflict after all it is difficult to imagine the environment in which the nagornokarabakh problem first emerged in 1988 methodology women were arguably among those most affected by the karabakh war and the lack of a formal assessment of the situation regarding women directly or indirectly affected by the conflict in the region remains a shortcoming it is important to clarify the challenges faced by conflictaffected women and what should be done from their perspectives the main goal is to understand from the perspective of a woman who survived the karabakh conflict considering the impact of the 19881994 and her 20162021 wars the study also aims to clarify how rural women feel about conflict and its resolution to achieve an inclusive and lasting peace womens voices need to be heard and understanding womens perspectives is essential to prepare people for peace by documenting these perspectives it shows how local and central governments should pay attention to the voices of conflictaffected rural women although some studies have been conducted on the effects of the karabakh war most of the researches approach the event from a general point of view in addition it is considered that there is a limited amount of studies on the karabakh conflict that lasted more than thirty years therefore this research examines the problems experienced by women who live close to the frontline and directly experience the effects of the war it is important to understand the feelings of women who suffer from irreversible pain furthermore it is seen as an important aim of the research that it helps to evaluate the karabakh conflict in a wider framework by shedding light on the studies planned to be done in the future the research population consists of the barda district which is very close to the frontline the sample consists of 10 women who were personally affected by both karabakh wars due to the number of participants included in the study and certain limitations it is not possible to generalize the study to cover the whole district however it is considered important in terms of being an important preliminary source for future research and providing a source for the literature the method used in the research is indepth interviews which is a technique of qualitative research method which were conducted with 10 rural women aged over 32 who witnessed the war directly or indirectly from different villages of barda taking the socioeconomic status of the women involved in the interview have been living in rural areas with their families and two of them are uneducated the rest are educated and working as a nurse and teachers the income level of interviewees is medium and low the research was guided by the following questions which provide insights into the problem 1 how the karabakh conflict has impacted the lives of women in the barda region 2 what peace and security mean for the women 3 what the role of women is in the peacebuilding and peacekeeping process 4 future perspectives on living together again of armenia and azerbaijan communities 5 womens recommendations or advice for the future generation towards armenia and azerbaijan relations analysis of the interviews and key findings karabakh conflicts effect on rural women azerbaijan has one of the highest percapita populations of internally displaced persons however sometimes these benefits for idps have been met with dissatisfaction by the local population there are many reasons for dissatisfaction among the local population such as reduction of employment opportunities especially the increase in population density in urban centers tuition fees high taxes and other budget expenditures as it is mentioned above the conflict between armenia and azerbaijan started in 1905 and recrudesced in 1918 however despite all the sufferings both nations tried to live together peacefully in the regions until another armenian invasion began in 1988 the good neighborhood atmosphere with the armenian people before the war turned into mutual hatred chaos and the emergence of endless problems in general while analyzing the interviews it could be observed that all women described a peaceful life in the absence of discrimination and disputes with the armenians until the armenian invasion started in 1988 participant 1 it was my wedding day in 1988 my friends came from the territory that they had a fight between armenians and azerbaijanis at that time they came here and talked about that fight the anxiety on their faces could be easily and obviously realized how they were scared from that time until now this war is still going on when the 20 january 3 happened in 1990 i was married i lived with my fatherinlaw and this affected us all awfully every time i watch it on tv i even remember that my father spoke what he heard to us nervously and lamentingly during that time the killing of innocent people especially the khojaly tragedy 4 affected us terribly the killing of innocent people overnight was blood and thunder refugees came from kalbajar and aghdam 5 it was heartbreaking to see the plight of war and the people of our village did their best to help them despite this those people were forcibly expelled from their warm homes we used to live with the armenian people as friends and neighbors but since then our hatred for armenians has increased as respondents state the karabakh war brought disaster death pain as well as social problems that emerged right after the war to the region another woman expressed that this conflict made her entire life psychologically unbearable and even in her dreams she feels that she is in the war again and again 3 january massacre was a violent crackdown on the civilian population of baku on 1920 january 1990 as part of a state of emergency during the dissolution of the soviet union 4 the khojaly massacre was the mass murder of ethnic azerbaijanismostly civilians but also armed troopsby armenian armed forces and the 366th cis regiment of the soviet union in the town of khojaly on 2526 february 1992 this massacre was the bloodiest tragedy of nagornokarabakh conflict 5 kalbajar and aghdam are the cities which were occupied during the i karabakh war participant 2 when the armenianmuslim6 conflict began in 1988 we were directly involved in that conflict so it almost had a huge effect on my youth and childhood it was never erased from my mind because i entered my firstyear university the pedagogical university in 1992 during the sharpest period of the war when i returned to the village for a summer vacation in 1993 it was the occupation year on august 23 i had an engagement day and our village was occupied on that day i went out with my fiancés family therefore both the first and second karabakh wars affected my lifestyle and psychics after the occupation of our village i studied at the university but nevertheless when i saw our village in a dream i never saw it as in peacetime i thought we were running away armenians were coming and shooting for a very long time gradually my psychics normalized a bit but i think that living a refugee life living the war will never be erased from anyones psychics those longsufferings first the difficulties of the soviet era the transition period the poverty then the loss of home relatives and people you know its true we didnt know that much when we were young and the soviet youth didnt have that much patriotism young people are more patriotic the deaths of two people during the first world war had an awfully enormous effect on me one was the death of chingiz mustafayev and the other was my sisters fiancé who died in that war and we were close friends family friends lost to my classmates and relatives it is as if everything you see with your eyes suddenly disappears and is destroyed we encountered those hardships at that time but during the second karabakh war it probably affected me worse psychologically because i had a family then now i was a mother so it affects me more im afraid of losing my children when im a mother and you have empathy for the mothers of dead martyrs a little girl had died in garayusifli and i couldnt help myself when i saw his gaze karabakh war has also huge economic effect on the women that caused plenty of problems he also worked as a deputy at the grain factory we witnessed the occupation of aghdam saw the martyrs and the wounded went through severe trauma and then moved from one region to another gakh sheki regions and baku city we finally came to barda7 and began to live here those events were a heavy blow to me we suffered a lot we did not find bread for weeks and we suffered a lot in general the karabakh war has had a very negative effect on the lives of people especially idps mainly women and it seems that the psychological traumas along with the physical injuries as well as financial and social harms will not be erased from peoples memory and lifestyles for a long time rural womens remarks on peace and security although certain agreements were repeatedly reached during the nearly 30yearold karabakh war peace talks failed the protracted conflict and the fact that politicians always come back empty from the negotiation roundtables especially the april escalation in 2016 there had a very negative effect on the trust for peace of both nations after the second karabakh war in 2020 women said they did not want war at all and wanted peace all women interviewed were in favor of peace and emphasized that the war did not benefit anyone they hope that with the liberation of the occupied territories the conflict would end with the signing of a peace agreement it can be observed that for many women peace could be defined in two categories living without war and danger and experiencing no fear and anxiety this means that there is a need for a stable country and community and that the chances that a new war will happen are very little the second meaning can be seen as a personal need of the women for psychosocial support programs which would help them to address their constant psychological traumas and anxiety participant 4 when i say peace i mean calmness and prosperity for all it would always be good if there was peace war did not give anything to anyone why should death and bloodshed be peace is to live calmly the conflict resolution is also a period of peace some believe that armenia is ruled from abroad and they are forced to occupy azerbaijan territories and blame the other side for that participant 5 peace means the resolution of the conflict in fact if the conflict is resolved there will be peace peace is when people have no fear no protection for example i would like to live comfortably without the police or the army but i must know that nothing can happen just as there are countries in the world where there is peace it does not occur to anyone that someone can invade switzerland america that an american citizen should fear war i want our people to live like that we have a right to do so we all are humans gods creatures both sides must be in the same position to resolve the conflict they do not accept our position if they do not have outside interference if they live according to the peoples desires perhaps peace will be possible the years we lived together peacefully we wrote songs people came and went became relatives and friends and stayed at each others homes i saw so many armenians who came and stayed in our houses worked as craftsmen and they treated us kindly now 30000 armenians do not live in baku on their own they do not want such conflicts but what can we do conflicts are controlled from the outside the occupants cannot do anything they are irritated from the outside for 29 years idp women have been living in a «suitcase mood» and after the liberation of their hometowns in 2020 most women consider themselves happy however they still have some concerns about moving back to their homes due to the security issues and the resumption of war women think that living secure means no need to be afraid of anything or feeling calm participant 6 you are secure from something you are afraid of you are not in danger wherever you go and you can come and go easily you can do your job comfortably thats security i think after coming here barda from aghdam there was a war going on they were shooting at aghdam and tartar 8 but we were not afraid that they would not shoot at barda but after the 44day war they threw a lot of missiles at barda the remains fell on us how many people died i was always afraid of the sound after that explosion most women who took part in the research expressed a fear of the reoccurrence of the war and cannot believe that this ends because of the daily news on the media they followed participant 7 during the 44day war i did not normally sleep through the night without fear even if everyone was asleep i couldnt sleep i was afraid that at any moment there could be an explosion a tragedy while i was asleep thats why i havent had a quiet night in 44 days this is the danger i taught during the day the house suddenly shook and i had to stop the lesson you know how painful it is to see that fear and anxiety in the faces of children this is the danger for me safe life is to live without the sound of bullets and no fear of war death or blood if peace is not fully established i cannot say that i feel completely safe because even today we feel that there are shootings in nakhchivan 9 and in certain regions which gives us reason to worry that the threat has not completely subsided that is why we are still in a state of turmoil to sum up women are in favor of peace and they consider that war does not benefit anyone however they believe that even though the war is over there is a probability of recrudescence of the war and it is stated that the fear of war will not end before the peace agreement is signed 8 tartar is located in the west of the country and belongs to the upper karabakh economic region the district borders the districts of kalbajar goranboy yevlakh barda and aghdam 9 the nakhchivan autonomous republic is a landlocked exclave of the republic of azerbaijan the region covers 550275 km 2 with a population of 463000 bordering armenia to the east and north iran to the south and west and turkey to the northwest the role of women in the peacebuilding and peacekeeping process regarding the role of women in peacebuilding it was assessed not at the political level but at the household level interviewees think that a woman is first and foremost a mother a nurturer of her children and if a woman teaches her children love compassion and the sin of killing others to their children it is a contribution to peacebuilding most respondents said that men fight in the war and the consequences of the war were more burdensome for women because a woman who loses a child a husband or a brother is deeply traumatized and can never escape grief some of the interviewees who think that azerbaijanis are more tolerant and compassionate underline the importance of teaching armenian women to be compassionate to their children participant 8 a woman is first and foremost a mother an educator the role of a mother is great and her respect is great we have brought up our children in such a way that we have always wanted peace we have brought up the child in such a way that we can share what we have with a friend be kind love the whole world love the people and so on but unfortunately i would say to the armenian women to bring up their children and future generations like us so that they do not go into conflict with their neighbors and people there is no end to the conflict everything changes and they must understand that my role in peacebuilding is that if i am a teacher first i tell children to be patriotic not to leave the village no matter how scared i was in 44 days i still couldnt leave first everything is solved by love the love of elimination the love of my people my family it would be great if we could form these qualities in a person during the interview process the women mentioned that they do not have any certain active women in their region who dedicate their activities to the peacebuilding process except a woman from jijimly village she also stated that if women control the war they will not let it happen participant 2 now is the time when i think that peacebuilding also needs brave ones to go and take part otherwise they will be lynched by others as a traitor on both sides either from that side or from this side true i suddenly think i look at it from the armenian side there are young children without two arms and we have too i think no mother wants to experience it whether it is this side or that side but in the end this conflict must be resolved so that no one can experience it again i think that if women run the war they will not allow it to happen generally according to the results of this part women are supposed to be mothers and busy taking care of families as well as no clues to know any women role models in the peacebuilding and peacekeeping process in the country especially in the rural parts and outside of the capital baku as women are excluded from the peace talks due to traditions and mindsets especially in patriarchal societies they cannot imagine themselves taking part in peacebuilding activities future perspectives on living together again of armenia and azerbaijan communities and recommendations by women for future generations in a militarized patriotic nation where the other is consistently portrayed as a threat irrevocably different and less peaceful or willing to compromise imagining peace can be a difficult task throughout history many people have managed to live together for centuries even though their languages religions and origins are different and they continue to live in the caucasus one of the most difficult regions of the world despite the war however there is suffering in the region because of the desire of some strong states to become more powerful and the dream of some weak states such as armenia to become bigger almost none of the women living in the region expected that the armenians would attempt such an invasion despite some painful events in the past however the suffering had turned into neverending anger in the hearts of women these sufferings destroy the possibility for both communities to live together most of the women participating in the research stated that it was not possible to live with them in any way due to the endless persecution of armenians for nearly a hundred years each of them expresses their reaction by saying it seems to me that living together with armenians will not happen we will see those days again we will experience that stress and excitement no i do not believe it i trust both our army and the president it will not be possible to live together again because we lost a lot the only son of the family was killed even if we live with them we will always have hatred in our hearts for them and we will want to avenge our losses therefore it is better not to live together a woman who lost her brother during the ii karabakh war in 2020 in consequence of armenias missile attack on barda on 28102020 articulates that even she is ready to give up her native lands if the armenians continue to live there participant 10 there are many people who think like me we do not want to share the same territory with armenians people are already so aware of their character that most of them are women for example men sometimes make friends with each other but women especially mothers who have lost a son never want to live in the same region with them and i am sure that there will be conflicts in the future even if they are forced to live together even if the conditions require it even if intergovernmental agreements are signed the conflicts may escalate in my opinion a ceasefire was signed again on november 9 who will stay there personally no one can take me there i will give up on the land where they live even if it is mine my opinion on this is firm no matter what is offered to me no matter the circumstances no matter the position there is a saying among the people i have no stomach for seeing them nothing can force me regarding womens advice or recommendations to the future generations most of the responses are about getting an education and being intelligent not forgetting the history and remembering always the enemy as well as being careful in terms of relations with armenians i would recommend to the next generation to be educated an ignorant person cannot make the right decisions an educated person is an intelligent person a person with a normal level of education and humanity whether in a conflictfree period he or she never forgets that the enemy is the enemy they say dont forget your past because it is the teacher of the future it is clear what we have experienced in the past i have lost my brother in the second karabakh war and above all in the first karabakh war khojaly tragedy cannot allow me to forgive armenians let the organizations defending the armenians the countries that support azerbaijan read the khojaly tragedy at least once and look at the facts some women blame the older relatives that they did not remind or tell anything about the armenians vandalism towards azerbaijanis in history therefore in the 1990s they did not imagine that someday armenians could kill azerbaijanis i am angry with our older generation because my grandmother said everything but not once did she tell us about the armenianmuslim war so that we would remember something at least be careful although the hearts of women continued to burn they tried to express uneasily that it was possible to live with them again but their biggest fear is insecurity because they had experienced this situation many times and each of them lost a life of their own in return i am not sure that this case will be completely real now and that the armenian people thinking like us will not hit us from behind again in a peaceful way without using tricks on us because we have lived this past many times and if i say today yes i am absolutely convinced that we can live together again in a completely safe environment i personally do not believe it for many years we gave the armenians a place to live but they hit us from behind during the years we lived with them i started from goycha district we lived together then we were oppressed we lived again we were hit from behind shortly it is obviously seen that living of two nations together again is almost impossible at least within 10 years as some interviewees mentioned the traces and scars of the previous war are so recent it will take more time to recover and forget what happened in order to live peacefully again conclusion the karabakh conflict which has been at its worst since 1988 and resulted in the violation of azerbaijans territorial integrity in the 1990s has left thousands of dead missing and maimed as well as psychologically traumatizing both nations available information on the death toll is very controversial different sources provide numbers that vary between 18000 and 30000 deaths the intensity of the conflict varies significantly depending on the death toll estimates in the undeclared war 20000 azerbaijanis were martyred 5000 were disabled and 100000 were injured the number of refugees and displaced people has exceeded one million 3890 azerbaijanis were also missing on 27 september 2020 a new largescale war erupted that lasted until 10 november with a ceasefire by russia it brought an end to the deadliest fighting the region had witnessed in nearly three decades with over 7000 military and about 170 civilians killed and many more wounded according to azerbaijan the fighting left 2907 azerbaijani soldiers and 95 civilians dead while 6 azerbaijani were still missing armenian authorities stated that the fighting had left 3825 armenians dead nagornokarabakh is a potential transit zone for the region as it can link the caucasus and europe for the purpose of trade while investment in the economy of nagornokarabakh could fulfill this capability the existing conflict has frozen the potential for prosperous economic relations throughout eurasia the karabakh war was not only a loss of life but also caused great economic damage to both countries especially azerbaijan in addition the development of trade relations in the region has been slow due to the presence of a hotbed of war in the region and the lack of ties between azerbaijan and armenia as well as the closure of borders the damage caused to the azerbaijani economy because of the war is about 535 billion the negative effects of the conflict have been reflected in the migration crisis in the two countries faced due to the conflict many local azerbaijanis and armenians in the region were forced to leave their homes in fear of being persecuted moreover this migration crisis has led to an increased urbanization in the south caucasus region in the case of azerbaijan people started to migrate from the nagornokarabakh region to other parts of azerbaijan especially baku and other larger cities creating a massive increase in urbanization considering the results of interviews with 10 women it can be obviously seen that the karabakh conflict has had a huge negative effect on womens lives mentally economically and socially as answers to questions about the impact of conflict on women show the karabakh war has had a very negative impact on peoples lives especially on internally displaced people mainly women with psychological trauma turning into physical wounds the economic and social damage will never disappear from peoples memories and lives the countrys long history of war has left the role of women in society as housewives and deepened gender inequality this can be seen in the responses to the question the role of women in peacebuilding the role of women in peacebuilding has been assessed only at the household level at the same time the lack of recognition of women peacekeepers in society indicates that there are few or no women working in this field or perhaps they refrain from working openly due to the fear of getting a hammering in the society according to the participants women are said to be mothers busy taking care of their families and especially in rural areas outside of the capital city baku they do not know female role models in the process of peacebuilding and peacekeeping in the country especially in patriarchal societies women are excluded from peace negotiations by their traditions and ways of thinking so it is unimaginable to participate in peacebuilding activities according to the interviewees they want no war and the conflict to end peacefully and the failure to sign a peace agreement between armenia and azerbaijan shows that the threat has not yet been completely subsided in particular the daily coverage of ceasefire violations in the media creates fear in society and enables to form an impression that there is a threat of war at any moment women support peace and believe that war benefits no one but even if the war is over it may break out again and until a peace treaty is signed the fear of war will continue and it is believed it will never end the 2 wars as consequences of repeated escalations and skirmishes between armenians and azerbaijanis have created hatred and mistrust in azerbaijani society so respondents to the question of the possibility of coexistence with armenians were almost negative it follows that the lack of international diplomacy has led to a gap between the two communities and has prolonged the karabakh conflict clearly it is almost impossible for two nations to coexist again within at least ten years as some interviewees have noted the wounds and scars of previous wars are very recent this will take longer to recover and forget what happened to live in peace again in general the recent history of the 44day war and the fact that barda was also badly damaged by the missiles and the loss of lives have deepened peoples hatred towards armenians i think that the fact that this conflict was frozen until september 27 2020 created a forgetfulness in people as if everything is in the past the freshness of the wounds of the war and the propaganda of the enemy image on both sides will slow down the peacebuilding process which will affect the processes in the region the results of the interviews clearly showed that women have mistrust hatred and anger towards armenians and in addition almost all women have expressed a negative attitude towards the idea of living together due to distrust and fear of armenians in an international context this topic has been little studied so far this is seen as an important factor in which rural womens opinions are not taken into account although some research has been conducted on the effects of the karabakh war most researchers approach the conflict from a general point of view as previous studies have shown only men participate in the peace process in patriarchal societies while women are excluded from the peace process because of social norms and stereotypes against women the enemy identity formed in azerbaijani and armenian societies have had and will continue to have a negative impact on the peacebuilding process to sum up some steps need to be taken to support womens participation in peacebuilding  firstly hate speech at the state level should be reduced  encourage womens social and political participation  eliminate womens economic dependence and achieve their integration into the economy  involve women in peacebuilding  identify a link between peacebuilding and livelihoods  bringing azerbaijani women together with armenian women or listening to each others memories of the war  creating conditions for dialogue between armenian and azerbaijani women etc annex1 photographs authors note this research was prepared as part of the ww2 peace project with the financial support of iac berlin najafizadeh m ethnic conflict and forced displacement narratives of azeri idp and refugee women from the nagornokarabakh war

 the karabakh conflict has harmed women mentally economically and socially and women do not support the warthis war has exacerbated gender inequality women peacebuilders are not recognized by the publicthis study is crucial because of highlighting conflictaffected womens challenges and what should be done from a female perspective

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introduction gun violence in new mexico within latine communities is on the rise and shows no signs of slowing down in 2019 new mexico rated as the eighth highest state for firearm homicide in the united states and the 6th highest rate of gun suicides and gun suicide attempts in the us in 2021 of all fifty states new mexico has the highest rate of gun deaths among latine people in new mexico 62 of gun homicide victims are latine in comparison nonlatine white residents of new mexico make up only 21 of gun ihtp 3 352364 2023 cc byncnd 40 issn 25639269 homicide victims this is an issue given that nearly half of the population of new mexico identify as latine potential reasons for higher rates of gun violence in new mexico have been investigated and include lax gun violence prevention laws high rates of gun trafficking within the state and lack of institutional resources to support gun violence prevention efforts among latine populations gang activity and drug use have been considered as reasons for higher rates of gun violence however these explanations have largely come from law enforcement rather than latine people or researchers embedded within latine communities the disparities in gun violence experiences are also viewed as a mirror of the structural and social position factors which negatively and disproportionately impact latine people these factors include income education occupation and health service availability research pertaining to the structural factors related to gun violence for latine persons has revealed several health inequities related to violence including officerrelated shootings involving latine people extreme socioeconomic disadvantage and higher rates of communitylevel risk factors such as poverty unemployment tenuous legal status and insecure housing in response to firearmrelated deaths nearly doubling over the last decade new mexican legislators have been pressured to implement gun violence prevention policies two such policies that passed in 2020 expanded background check requirements for firearm purchases and permitted guns to be seized from individuals deemed to pose a threat to themselves or others these policies and others like it are categorized as red flag laws which allow law enforcement family members school administrators and mental health providers to petition courts to restrict a persons ability to possess firearms based on the threat of future harm other gun violence prevention strategies have included public education programs to increase knowledge about the costs of gunrelated violence these public education programs have included information on gun safety and presentations on the impact of gun violence as shared by trauma surgeons however well intended these strategies often fail to address the structural inequities that underlie the rise in gun violence within latine communities in addition to being the leader of firearm deaths latine individuals made up 57 of the new mexican prison population in 2021 compared to 25 for whites and 82 for black people this incarceration rate is also 22 higher than the national average of latine persons in prison latine persons in new mexico also lead in arrests being 12 times more likely to be arrested than whites these statistics and many others point to structural factors that may explain the disparities in gun violence experienced by latine persons in new mexico however as of this date knowledge on this topic remains underresearched and unknown also unknown are the perspectives of latine people regarding their experiences with both gun violence and gun violence prevention there is an urgent need for research to better understand the unique experiences of latine persons and their experiences in both gun violence and prevention from a social ecological perspective examining the structural barriers and facilitators which impede latine involvement in gun violence prevention is critical to interrupting the cycles which render this group more susceptible a deeper understanding of the factors associated with both gun violence and prevention is crucial for developing informed and culturally sensitive policies and interventions objective this conceptual article explores theory and research to better understand how gun violence impacts latine communities and creates a conceptual framework to improve healthcare workers ability to encourage empowerment and efficacy regarding latine engagement in gun violence prevention efforts the objective of this paper is to analyze research from social science and health disciplines focusing on the experiences of latine persons and groups experiencing gun violence and engaging in ihtp 3 352364 2023 the purpose of this integration is to locate latine levels of empowerment and efficacy in gun violence prevention based on social ecological spheres of influence mediated and influenced by permutations of structural violence finally the fourth section will provide the limitations and directions for future research emphasizing the implications for healthcare practitioners and researchers literature review this section reviews the scope and quality of empirical literature related to gun violence and prevention strategies among latine populations the goal of synthesizing and analyzing empirical literature is to identify and analyze gun violence prevention efforts within latine communities in the united states other goals are to provide information on latine perceptions toward gun violence prevention strategies and explore the barriers and facilitators to participation a literature search was conducted to locate empirical articles discussing gun violence in latine communities and activities interventions to prevent gun violence using the key words and phrases latinoaex hispanic gun violence and gun violence prevention databases including pubmed google scholar psycinfo jstor web of science proquest and worldcat were searched to locate articles articles published between 2005 and 2023 were considered for inclusion articles were excluded if they focused on forms of violence other than gun violence were not peer reviewed or were not evidence based books and book chapters were also excluded also omitted were research studies unrelated to gun violence including studies of domestic violence and intimate partner violence and literature reviews and references the literature search was run in may of 2023 gun violence trends in the united states gun violence in the united states was relatively stable from 1999 to 2014 but after 2014 rates of gun homicide began increasing in 2020 there were 19384gun homicides in the united states the gun death rate in the us is much higher than in other comparable western countries in 2016 the us gun death rate was 106 per 100000 people compared to three next highest western countries canada australia and france the exorbitantly higher rate of gun deaths in the united states has led to questions as to the reasons for this unfortunate phenomenon as well as its ramifications gun ownership gun ownership in the united states is much higher than in any other comparable country with 1205 civilianowned firearms per 100 people in 2023 the united states civilian gun ownership is nearly double that of the secondplace country the falkland islands in 2017 us civilians owned an estimated 393347000 total firearms measured against a population of 326474000 in the same year also in 2017 30 of american adults say they currently own a gun and another 11 say they dont personally own a gun but live with someone who does the rate of gun ownership in new mexico is 462 falling solidly in the middle in terms of gun ownership by state gun ownership among latine individuals is on the rise black or latine individuals represented 30 of all us gun owners in 2015 suggesting the racial demographics of gun owners may be shifting since 2019 an estimated 40 of firsttime gun buyers have been ihtp 3 352364 2023 cc byncnd 40 issn 25639269 black or latine research into the opinions of latine gun owners has been limited but is beginning to emerge a recent qualitative study of the perspectives of latine lgbt asian and black firearm owners found that most respondents did not feel a part of the mainstream gun culture deeming it necessary to form their own communities of diverse firearm owners gun purchasing gun purchasing in the us reached record levels in 2020 with an estimated 2340 of purchases being firsttime buyers although laws vary greatly by state some federal regulations exist on gun purchasing nationwide the gun control act of 1968 which regulates firearms at the federal level requires that citizens and legal residents must be at least 18 years old to purchase shotguns rifles and ammunition all other firearms can only be sold to people 21 and older additionally fugitives and patients involuntarily committed to mental institutions are among those who are prohibited from purchasing guns although enforcement of these laws vary by state another policy regulating firearm purchasing is the brady handgun violence prevention act otherwise known as the brady bill enacted in 1993 the brady bill mandated federal background checks on firearm purchasers in the united states and imposed a fiveday waiting period on purchases this intent of the brady bill was to prevent persons with previous criminal convictions from purchasing firearms gun carrying gun carrying is more common in places characterized by higher levels of violence and is viewed by carriers as a protective measure to improve safety previously published literature on gun carrying widely concludes that men carry guns to assert masculinity and cope with socioeconomic disadvantage a recent study of gun carrying among women found that a growing number of women view gun carrying as a tool for empowerment viewed as creating a more equal playing field between men and women and lessening their chances of experiencing victimization of a national sample of 3103 respondents women reported greater gratification from their gun ownership than men however indicators of race or ethnicity did not impact gratification from gun ownership research has shown that both nongun owners and gun owners express feeling less safe when perceiving more guns were owned by members of their community one recent study which examined public perception of gun carrying found that in a sample of 3949 american adults including an oversample of gun owners and veterans fewer than 1 in 3 supported gun carrying in any of the specified venues additionally support for gun carrying was higher among gun owners than it was for nongun owners another similar study examined american perceptions of open carry by studying perceptions of safety across various locations in a sample of 250gun owners and 250 nongun owners this study found that respondents felt uncomfortable in a situation involving open carry and even less comfortable when the person engaging in open carry was a stranger gun owners whites and those with higher levels of education all expressed greater feelings of perceived threat in relation to gun carrying however these two studies were anomalous in the research available regarding perceptions of gun carrying most recent empirical research available regarding gun carrying focuses on the gun carrying behaviors of juvenile or adult offenders particularly black men and latine adolescents and adults who use substances or who have experienced bullying or dating violence no recent studies were found examining latine perceptions of gun carrying behaviors or laws perceived safety and threat of gun violence perhaps as crucial as gun violence itself is the concept of perceived safety along with its antithesis perceived threat perceived safety involves maintaining trust loyalty and credibility within social networks communities and internally for individuals it also involves feeling safe with the policies and institutions that govern everyday life recent research suggests that perceived safety regarding gun violence is derived from several factors including levels of crime in the community police presence neighborhood ihtp 3 352364 2023 cc byncnd 40 issn 25639269 disadvantage and the presence of guns perceived safety has also been found to be associated with individual factors including mental health status and risk behaviors it has also been found to be associated with communitylevel factors including collective efficacy characteristics of policing and experiences of personal victimization researchers have defined perceived threat as the awareness of nearby impending threat regardless of fewer direct personal experiences with violence feeling unsafe and vulnerable to gun violence has been shown to negatively impact individual wellbeing community relationships and neighborhood cohesion perceived threat leads to stress poorer quality of life and health problems for both children and older adults additionally feeling unsafe can create a culture in neighborhoods which permits violence and crime because fearful individuals do not interact and bond with neighbors or participate in collective efforts to improve the area as a result community norms go unnoticed or unenforced problems with violence increase and this context leads to further mistrust among residents research into the drivers of perceived safety and threat related to gun violence is slowly beginning to emerge a recent study involving 820 household surveys of residents from high moderate and low violence areas found that collective efficacy was consistently important to residents feelings of safety across all contexts in this same study residents from areas with moderate levels of violence felt the least safe despite reporting hearing gunshots less frequently seeing police less frequently and being stopped less frequently by police than in the high violence area this is significant given that 89 of residents in the high violence area reported hearing gunshots compared to 70 from the moderate violence area and 30 in the low violence area additionally perceptions of gun carrying and the reasons for it were reported differently by residents living in areas with different levels of violence gun carrying was viewed as most common in the high violence area followed closely by the moderate violence area in both areas gun carrying was largely believed to be for protection with 29 of individuals in the high violence area believing it was to commit crime versus 14 in the moderate violence area in the low violence area only 1 of residents reported gun carrying as being very common believing that gun ownership was primarily for sport or hunting no recent studies were found examining the drivers of perceived safety and threat among latine populations regarding gun violence desensitization to gun violence prior research suggests that living in high violence areas or being exposed to frequent violence makes individuals become psychologically desensitized perceiving the violence as normal this desensitization emerges as gun violence becomes normalized within a community causing residents to pathologically adapt over time by suppressing their distress to acclimate to the dangerous environment a recent study examined the drivers of perceived safety in a survey sample of 820 household surveys from high moderate and low violence areas results found that neither victimization or hearing gunshots was related to feelings of safety a rationale offered is that these residents are coping with the daily strains of violence by dampening their visceral response to violence to avoid experiencing prolonged distress or fear thereby becoming desensitized to the violence around them gun violence and latine populations a challenging component in reviewing literature is that it is difficult nearly impossible to find recent empirical research on gun violence and prevention specific to latine communities that is not conducted in contrast with other racial or ethnic groups this is concerning given the overwhelming representation of latine among those who are fatally and nonfatally injured due to gun violence another challenge is that there is very scant literature found that speaks to the unique lived experience of different latine communities such as mexicans peruvians guatemalans or others this absence speaks to a structural inequity experienced and known in research with latine populations where latine ihtp 3 352 353 354 355 356 357 358 359 360 361 362 363 364 2023 cc byncnd 40 issn 25639269 groups are relegated to the periphery or excluded entirely from western knowledge societies this is evidenced in the literature search conducted for this review using the words gun violence and hispaniclatinolatinelatinx the largest number of peer reviewed articles available were 76 and the lowest was 1 furthering the narrative of marginality most items found were not peer reviewed articles but newspaper articles or book chapters this speaks to the narrative of illegibility assigned to latine populations constructing a narrative where members of this community can only be seen as outside of the mainstream narrative of gun violence or in comparison with other racial or ethnic groups only one empirical study was found that was specific to the experiences of latine populations focusing on the impact of latine immigrant concentration as it relates to violence this study challenged the ethnic heterogeneity hypothesis which claims that latine immigrant presence in neighborhoods is associated with social disorganization and reduced community cohesion resulting in increased violence the authors contrast this with the immigrant revitalization hypothesis which claims that residence in immigrantconcentrated areas has been found to be associated with reductions in crime increased community trust and mutual expectations for informal social control among residents the authors argue that immigrant concentration may create fragmentation at lower levels but will lead to integration at higher levels when the benefits of immigrant concentration emerge as is stated in the ethnic heterogeneity hypothesis lower levels of immigrant concentration occur when immigrants begin to reside in a community in smaller numbers higher levels of immigrant concentration occur when the immigrant community grows developing social networks and institutions which support the immigrant community the authors test the association between latine immigrant concentration and collective efficacy positing that this association will be negative at low levels and positive at higher levels of immigrant concentration census data from the cities of los angeles and chicago were used to examine individual and neighborhood factors in relation to collective efficacy measured by a scale adapted originally by sampson et al collective efficacy was measured using two scales developed originally by sampson et al to represent informal social control and social cohesion both were measured using fiveitem likert scales for informal social control participants were asked about the likelihood that their neighbors would be counted on to intervene in various ways such as if children were seen skipping school or if a fight broke out in front of their house for social cohesion and trust participants were asked about their level of agreement with items such as whether people in their neighborhood generally got along or were willing to help one another results confirmed the authors hypotheses in both cities finding a negative association observed as latine immigrant concentration emerges then exerting a positive influence on collective efficacy at higher levels of immigrant concentration analysis of theoretical perspectives on structural violence empowerment and collective efficacy and social ecological models the conceptual framework proposed in this paper integrates structural violence theory social ecological theory and the theoretical approaches of collective efficacy and empowerment derived from a review of the literature and the authors indepth analyses of these theories the purpose of this integration is to locate latine levels of empowerment and efficacy in gun violence prevention based on social ecological spheres of influence mediated and influenced by permutations of structural violence structural violence structural violence is described as violence that is permissive sometimes encouraged and often goes unnoticed it involves the invisible social entities that create inequality and produce marginalization based on race class sex and other identities structural violence renders social issues such as poverty illness hunger and premature death as ordinary and taken for granted ihtp 3 352364 2023 cc byncnd 40 issn 25639269 so that no one is held accountable in modern times gun violence is rendered structural due to the policies culture and institutions that perpetuate it unevenly based on social location and racialized status in the united states gun homicide is ten times more likely to impact black americans than whites social ecological models social ecological models are conceptual frameworks which draw attention to health behavior and how it is framed by both individual and environmental determinants ecological models argue that a dynamic relationship exists between an individual and their surrounding environment this model derives from a systems approach to human behavior such that individuals are viewed as influencing and being influenced by people and organizations with whom they interact along with the surrounding community and societal norms the microsystem refers to direct influences such as interactions with family friends or coworkers the mesosystem involves interrelations among settings in which an individual is involved including schools or places of worship the ecosystem refers to facets of the larger social system which impact the individual including presence of gun rights or violence prevention organizations the macrosystem involves the cultural beliefs and values that influence both micro and macrosystems such as held beliefs about gun ownership and selfdefence when applying socioecological models to gun violence it becomes possible to identify the social ecological factors which produce barriers and facilitators to latine involvement in prevention socioeconomic disparities faced by latine persons in new mexico coupled with the lack of time available to devote to gun violence prevention may reduce their involvement in such activities within the community additionally personal beliefs about defending oneself and the fear of being labeled as a snitch may reduce a latine persons perceived ability to influence changes in gun violence within their community within the policy domain the tough on crime approaches taken by law enforcement do not center around the inclusion of latine persons in gun violence prevention thereby reducing their ability to become involved collective efficacy and empowerment empowerment is a process and outcome situated within social and environmental inequity that aims to shift power relations one of the foundational writers about empowerment paolo freire posited that empowerment comes not from a reform of the normal structures which maintain oppression but through the process of liberation which allows the oppressed to obtain a sense of self and identity separate from that of their oppressors an initial part of the process of empowerment involves a critical awareness and discovery of both the oppressed and oppressors manifestations of dehumanization liberation or empowerment frames consciousness raising of social inequities as the preliminary step to change these injustices this liberation extends to the oppressors allowing them to realize their own humanity through no longer engaging in processes which perpetuate dehumanization of the oppressed much empowerment research has focused on individual experiences of empowerment usually through psychological analysis this form of analysis is useful for psychological exploration of empowerment but can neglect the structural forces which may impede an individual or groups ability to exert empowerment to change the conditions which oppress them such as disparities in health or social disadvantage more research is needed that examines how indicators of individual and community empowerment both are associated with action this is particularly salient when researching the factors that encourage groups of people to become involved in collective efforts to ihtp 3 352364 2023 cc byncnd 40 issn 25639269 change conditions which impact them negatively such as gun violence collective efficacy is defined as a groups shared belief in its conjoint abilities to take actions required to produce change or the process by which social cohesion is activated as informal social control collective efficacy is usually measured by combining social cohesion and informal social control into one construct social cohesion is defined as the degree of trust solidarity and shared values among members of a community informal social control involves individual willingness to enforce social norms within their community in recent years collective efficacy has been viewed as an important concept for study among social work researchers that could guide interventions to strengthen communal empowerment gearhart asserts that creating a stronger link between collective efficacy and empowerment theory can help make collective efficacy more actionable for social work practitioners in his writing he describes collective efficacy as an explanatory theory meant to explain why crime and violence occur in communities on the other hand empowerment theory is conceptualized as a practicebased theory grounded in educational practice to explain how groups and individuals can gain greater control over their lives collective efficacy theory reflects empowerment as a process because it explains how communities mobilize to create change incorporating collective efficacy into the process of empowerment places a greater emphasis on uncovering and exercising the perceived collective power within communities to change social ills such as gun violence integration of theoretical frameworks and discussion the present paper reviews empowerment and collective efficacy theories social ecological models and structural violence theory to develop a model that conceptualizes the barriers and facilitators of gun violence prevention among latine communities in the state of new mexico the literature review in this paper also contributes to the development of a conceptual model by situating facets of the model in empirical evidence figure 1 depicts the conceptual model integrating these theories to conceptualize the ecology of gun violence prevention behaviors among latine communities in new mexico integrating an inside out social ecological model which incorporates empowerment collective efficacy and structural violence theory the model proposes a way forward with a new ecological framework that is dynamic and placespecific in explaining gun violence prevention activities among latine communities in new mexico this model connects the epistemology of ignorance of gun violence experiences and prevention within latine communities with the consequences of structural violence the combination of these factors then leads to outcomes regarding latine involvement in gun violence prevention finally these outcomes have the potential to be altered by possible facilitators for gun violence prevention including collective efficacy and empowerment the framework centers the reality of structural violence and epistemology of ignorance that have historically marginalized latine persons placing this group at higher risk for gun violence than any other in the state of new mexico the relationship between structural and gun violence is depicted demonstrating how disparities in gun violence experiences lead to unrealized potential for latine persons in new mexico further the perceived threat within latine communities is conceptualized as a form of structural violence placing latine people in a state of constant stress danger or desensitization to gun violence over time the causes of gun violence have become more deeply embedded creating greater structural inequities in the gun violence realities of latine communities in new mexico empowerment theory is incorporated to understand how consciousness raising and coalition building facilitate gun violence prevention among latine persons in new mexico empowerment is conceptualized as a possible intervention for engaging in gun violence prevention empowerment may influence who becomes involved in gun violence prevention in the first place for example people who feel more empowered might be more likely to participate in ihtp 3 352364 2023 cc byncnd 40 issn 25639269 gun violence prevention initiatives than those who do not informal social control and social cohesion from collective efficacy theory are also incorporated in the conceptual model as potential interventions for increased participation in gun violence prevention social cohesion among communitybased groups can result in successful communitybased collective action which increases collective efficacy social cohesion and informal social control can also occur as a result of participation in gun violence prevention engendering a sense of communal responsibility the gun violence experiences of latine persons inform the social ecological domains impacting involvement in gun violence prevention the policy and environmental domain is influenced by facets of structural violence specifically unrealized potential and the perceived threat of gun violence these experiences of structural violence explain the reduced or unknown participation in gun violence prevention among latine persons in new mexico and the current policies regulating guns or lack thereof the policy and environmental domain then influence the behaviors of communities and organizations which develop the agenda for gun violence prevention within latinedominant communities empowerment and collective efficacy have the potential to intervene in the relationship between gun violence prevention activities and structural violence wherein organizations and groups build coalitions to make decisions of how to reduce gun violence within their communities information is provided on the potential barriers to achieving collective empowerment and efficacy recognizing that the current ignorance of latine perceptions of gun violence and prevention efforts serves as a significant barrier to social cohesion and informal social control potential facilitators are also considered including the steps identified in previous research to increase collective efficacy and empowerment such as consciousness raising and coalition building the combination of intervening forces then influences the interpersonal domain which involves shared social ties and norms about gun violence prevention behaviors here collective efficacy and empowerment can also intervene as latine communities negotiate social cohesion and informal social control in the prevention of gun violence and development of shared norms around gun behaviors finally each of these domains influence the final domain representing the individuals gun violence beliefs and preventative practices centered on the collective and individual capacity for influencing gun violence trends particular attention is paid to a phenomenon unearthed in the literature review referred to as the epistemology of ignorance of latine experiences with gun violence and prevention strategies the conceptual model traces the lack of inclusion in knowledge production that renders latine persons in new mexico more vulnerable to experiencing gun violence at higher rates than white members of the same community this epistemology of ignorance then translates into a lack of knowledge regarding latine perceptions of gun violence and prevention resulting in a lack of effective policy to curb gun violence within these communities this lack of effective policy then carries out into the organizational domain manifesting as little to no connection between latine communities and the enforcers of gun violence prevention policies the lack of coordination between community and policy then influences the interpersonal domain manifesting as a lack of social cohesion and informal social control regarding shared beliefs and perceptions of gun violence within latine groups lastly this ignorance manifests as a lack of efficacy and empowerment from latine persons regarding their ability to effect change in gun violence within their communities when describing the relationship between gun violence structural violence and gun violence prevention for latine groups a social ecological approach positions gun violence in a broader social historical and institutional context allowing for the consideration of structural determinants of violence including race ethnicity gender socioeconomic status and location by centering the perceived threat resulting from structural violence this framework allows us to consider multiple spheres of influence from the individual to the environment and how these collude and combine to generate patterns in gun violence and prevention strategies for latine persons in new mexico informal social control and social cohesion from collective efficacy theory combined with coalition building and ihtp 3 352 353 354 355 356 357 358 359 360 361 362 363 364 2023 cc byncnd 40 issn 25639269 consciousness raising from empowerment theory provide means for intervening in the relationship between structural violence gun violence prevention behaviors and the resulting outcomes creating pathways to increased latine involvement in prevention initiatives implications gun violence has been shown to have lasting consequences on latine communities leading to disparities across social ecological domains including health buggs and zeoli point to the social determinants of health which predict disparities in gun violence including socioeconomic disadvantage and racial residential segregation which disproportionately impact racialized groups applying a healthcentered approach to gun violence prevention means adopting consistent messages about the preventability of gun violence promoting the use of evidencebased prevention strategies and encouraging collaboration among institutions including engaging members of the community most impacted by gun violence this approach is viewed by health researchers to be amenable to gun violence reframing it as a societal issue which connects people with their surrounding environments incorporating a social ecological perspective to understand both gun violence and prevention is essential in addressing the health disparities associated with this health crisis a review of the empirical literature has revealed a gap in the lack of research into both the causes and ramifications of gun violence based on current public opinions of gun ownership purchasing and procedures for maintaining safety gun ownership and purchasing has risen exorbitantly in the united states since the end of mandatory covid19 quarantine in 2020 as have incidents of firearm related deaths and injuries such experiences may have a lasting impact on public opinion of guns among groups public opinion may involve widespread acceptance of gun ownership sustained fear of the threat of gun violence or a desensitization to the presence of guns within communities future pathways to prevention should explore modern shifts in perceptions of both gun ownership and gun violence as these perceptions will have a direct impact on the effectiveness of proposed strategies aimed at preventing and reducing gun violence the most dire research gap identified by the analyses in this paper is the lack of nuanced data relevant to the gun violence experiences of latine individuals although a growing body of literature exists examining the gun violence experiences of racialized groups in the united states there are important identitybased differences of gun violence experiences between marginalized groups such as the impact of police surveillance and higher arrest rates among latine groups in relation to other racialized groups additionally the analysis made in this comprehensive paper highlights the striking lack of research related to latine involvement in or knowledge of gun violence prevention efforts within their communities in most of the empirical research reviewed the racial and social disparities underpinning gun violence were not reported as being important in the selection of prevention efforts pathways to prevention in future studies related to gun violence in latine communities should consider analyzing the potential facilitators and barriers to involvement in prevention activities and the level of agreement with current gun violence prevention policies conclusion this conceptual paper has articulated three main points historical and contemporary structural violence underlies the prevalence of gun violence among latine groups in the state of new mexico and also explains the lack of knowledge pertaining to their involvement in gun violence prevention gun violence prevention efforts must involve the participation and leadership of latine persons in order to be sustained and interrupt cycles of structural violence and collective efficacy and empowerment provide pathways towards sustained latine engagement in gun violence prevention efforts wherein such actions permeate community social norms and influence behaviors at the interpersonal and individual levels the analyses in this paper have demonstrated that placing gun violence prevention within latine communities in a placespecific context centering the structurally violent inequities and pathways to empowerment and efficacy is a way to ihtp 3 352364 2023 cc byncnd 40 issn 25639269 acknowledge and address the historical and contemporary forces that serve as barriers and facilitators to latine involvement in gun violence prevention the conceptual model developed in this paper operationalizes this lack of academic knowledge into an epistemology of ignorance where structural forces underpin the idea that latine perceptions of their gun violence experiences cannot inform policy or be used to effect change in the limited studies found that were specific to the experiences of latine persons this ignorance was conceptualized as a product of structural violence wherein the experiences of latine persons are deemed as unimportant or marginal to the grander narrative around social issues while disheartening this limitation points to a crucial area for future knowledge generation investigating the unknown rendering it known therefore future research should not only examine the gun violence experiences specific to latine groups but go further to examine differences between latine ethnic groups such as mexicans and cubans additionally future research should examine the facets of latine perceptions of and involvement in gun violence preventative efforts investigating both the barriers and facilitators to their participation and their relationship with collective efficacy and empowerment research and coverage of this topic make it abundantly clear that structural forces underlie the pervasiveness of gun violence within latine communities healthcare and other frontline social service providers are uniquely positioned to exist within structures and advocate alongside marginalized persons we are tasked with the dual role of both maintaining and interrogating the current systems to address structural barriers that create unequal life experiences for individuals and communities presently both social workers and public health workers are being called to address gun violence in the united states at the same time us federal funding to research gun violence is finally available after over twenty years of being prohibited this moment presents a window of opportunity to address gun violence the likes of which have not been present for over two decades to interrupt gun violence trends in latine communities it is imperative to prioritize interventions which encourage empowerment and collective efficacy by identifying the facilitators and barriers to involvement in gun violence prevention efforts

gun violence within latine communities in new mexico is on the rise and shows no signs of slowing down the disparities in gun violence experiences mirror the structural and social position factors which negatively and disproportionately impact latine people in response to firearmrelated deaths nearly doubling over the last decade new mexican legislators have been pressured to implement gun violence prevention policies however well intended these strategies often fail to address the structural inequities that underlie the rise in gun violence within latine communities there is an urgent need for research to better understand the unique experiences of latine persons and their experiences in both gun violence and prevention from a social ecological perspective examining the structural barriers and facilitators which impede latine involvement in gun violence prevention is critical to interrupting the cycles which render this group more susceptible a deeper understanding of the factors associated with both gun violence and prevention is crucial for developing informed and culturally sensitive policies and interventions this conceptual paper explores theory and research to better understand how gun violence impacts latine communities and creates a conceptual framework to improve healthcare workers ability to encourage empowerment and efficacy regarding latine engagement in gun violence prevention efforts the objective of this paper is to analyze research from disciplines in the social and health sciences focusing on the experiences of latine persons and groups experiencing gun violence and engaging in gun violence prevention

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introduction shisha is a tobacco product that is smoked communally in a water pipe narghile or hookah shisha smoking has origins in the middle east south east asia and northern africa 1 it commonly takes place in a cafe settingrestaurant 2 or other social gatherings over one or more hours like any tobacco smoking shisha contains harmful materials such as carbon monoxide nicotine and lead among others 3 4 5 according to the first international conference on water pipe tobacco research held in 2013 shisha smoking is a worldwide epidemic that needs urgent public health attention 6 shisha smoking is a particularly widespread practice among young people 7 8 studies from two universities in america found that the prevalence of any lifetime hookah use was 25 28 among university students 9 10 while studies from the uk indicated that shisha smoking was between 11 and 18 among university students and 8 among secondary school students 11 12 other studies have shown that shisha smoking is more in the general population than in university students 13 14 and shisha smoking starts at a mean age of 187 years 2 meaning that interventions to prevent the usage of shisha should start at an early age research to date suggests that shisha use among young people is promoted primarily through peer influence 12 15 16 as well as perceived benefits such as reduced anxiety and entertainment 17 18 19 many young people learn to smoke from friends especially in high school or university 17 youth are either taken to shisha cafes by their friends to smoke or they watch their friends smoke at their homes or at school 17 shisha use is also promoted through flavoured tobacco products 5 7 8 20 use of the internet 9 2124 and gaps in implementation of smokefree policies cases of noncompliance with smokefree legislation among the owners of shisha cafes have been reported 22 25 interventions targeting these reasons for shisha use have not been successful to date additional approaches are needed strengths and limitations of this study ► this study is one of the few studies done in the uk with an aim of exploring the use of niche tobacco a case of young peoples perception of shisha cafes ► all the participants recruited were found to be students results may not reflect the views of young people who were not in school ► majority of participants were south asians results may not necessarily represent the views of all young people in the uk open access shisha is well known to carry important meaning socially and among families 7 2628 yet little research has explored how this meaning could inform shisha cessation interventions given the high prevalence of shisha use among youth we conducted qualitative interviews of people aged 1830 years in the uk to explore the social functions ascribed to shisha cafes with a goal of identifying areas of intervention methods data collection after obtaining informed consent an interviewer trained in qualitative methodology collected sociodemographic information and conducted a single facetoface semistructured interview with each participant that lasted 3040 min the interview consisted of openended questions aimed at exploring young peoples perceptions of shisha cafes in leeds uk the interview guide was piloted to help in testing the adequacy of the questions 29 and modified accordingly data were collected at the office of the local community centre interviews were audiorecorded the primary questions asked were how do you feel when you visit this café what would you say has changed in your life when you started coming to this shisha café or any other what would you say is the significance that you attach to going to a shisha café and if there was to be an alternative to shisha what would that be and why additional questions were probes to further explore responses to the primary questions data analysis recorded interviews were transcribed and the generated textual data were analysed using thematic approach 30 31 in brief codes were initially identified from the first eight interviews following an iterative process with additional interviews the codes were refined and formalised as a codebook all interviews were then coded themes were generated and supported with illustrative quotations from the interviews participants were enrolled until thematic saturation was achieved results participants a total of 48 participants were identified and screened of these 31 enrolled in the study eight people declined due to lack of time for interviews five did not give any reason and four people were not comfortable to be interviewed by a stranger participant sociodemographic characteristics are shown in table 1 the majority were single male students in their 20s approximately half were south asian with the remainder split between blacks and whites themes the following themes were identified shisha use plays a central role in social interactions shisha cafes are pleasurable shisha cafes are implicitly sanctioned when used by respected professionals most but not all acknowledge that shisha cafes are harmful and shisha cafe use could be reduced through efforts aimed at the individual and the community shisha use plays a central role in social and cultural interactions most participants used shisha in cafes which served as a place where young people could meet to socialise i like going to shisha cafés because i meet different people while i am there we share different issues including school friendship and even familiesmale 27 years old some female participants of south asian origin highlighted that shisha cafes are the only places they can socialise with boys one of the participants said my father does not allow boys to come to visit me the only place i can meet the boys is a shisha café because my father allows me to go there this makes me interact with the boys and even share contacts if you do not interact with boys where do you get a many participants said that shisha cafes are relaxing settings where they can meet with friends and enjoy time together they emphasised the ability to develop their social networks through patronage of different cafes one participant said i sometimes travel a far distance from my home to meet up with my friends in different cafes its good to visit other shisha cafes that i am not used to as this increases on the network of friends which relaxes my mindmale 18 years old this network of friends however can have negative influence as well other participants stated that they used shisha out of peer pressure rather than a personal desire to use it they go to shisha cafes to be with their friends and end up smoking while there i have friends who smoke shisha in shisha cafes and i go with them too when i reach these cafes i have to take shisha as well because all my friends are taking shishafemale 18 years old some participants used shisha outside of cafes for instance shisha may be served at important cultural functions like wedding functions or burial functions it functions as a signal of welcoming complementing other activities like watching tv or having a drink in these settings participants viewed shisha smoking as a show of respect this was more common in south asians compared with other cultures if my friends come to visit me i have to prepare them shisha when preparing food i have to prepare shisha as well such that we as a family share with the visitorsmale 20 years old …… sometimes just to change home environment my dad takes us out to shisha cafés where we catch up with other friends and peersmale 24 years old shisha cafes are pleasurable in addition to enabling social interaction shisha cafes brought participants pleasure participants described the emotional benefits derived from the experience one participant stated when i am stressed i go to a shisha café when i am there i meet with my friends and i share with them my problems and i become psychologically finefemale 19 years old participants also found sensory pleasure through use of shisha they stated that different flavours put in shisha and the soothing noise of bubbling water coming out of shisha apparatus enticed them to frequent shisha cafes i like different flavours in the shisha i cannot even take a single day without going to a shisha café because of this flavour pineapple flavour is my favourite but there are different flavoursmale 25 years old you can imagine the kind of sound that come from bubbling water in the shisha machine very relaxing the sweet smell coming out while smoking a very sweet smell indeed i enjoy that all the timefemale 18 years old shisha cafes are implicitly sanctioned when used by respected professionals some participants reported that professionals including doctors public health officers and university lecturers smoke shisha participants expressed respect for these individuals and felt that shisha must be acceptable if they were using it one participant said i have friends who are doctors and lecturers who smoke shisha with me if a doctor can smoke shisha who am i not to take shisha these are respected people and we have to believe in what they domale 25 years old this implicit endorsement of shisha remained even when participants acknowledged the negative health effects of smoking shisha the behaviour of these respected professionals was seen as an endorsement of safety andor acceptability of many participants doctors always tell us not to smoke but they smoke they tell us not to take alcohol but they take it some of them even take shisha too i know all these risks are there but i will keep taking my shisha as doctors and other professionals domale 20 years old most but not all shisha smokers acknowledge that shisha cafes are harmful many participants clearly stated that shisha smoking has many negative consequences to their physical health one participant said a few months ago i started experiencing sleepless nights and increased heart rate when i am climbing a steep slope this started months after start of shisha usemale 20 years old another participant said i used to be a footballer and before i began using shisha i used to run without any problem but when i began using shisha my ability to run began to decreasemale 21 years old many participants specifically felt that shisha puts them at risk of getting cancer dental problems and cardiovascular diseases i have read from different sources that shisha smoking predisposes people who use it to different diseases including cancer of the lungs and cancer of the mouthmale 23 years old open access shisha cafe use could be reduced through efforts aimed at the individual and the community when asked about potential ways to reduce shisha use participants felt that nontobacco alternatives could be offered in shisha cafes that preserved the ritual of shisha smoking i would use any alternative without tobacco comfortably if the alternatives were served in shisha cafés share it as we do with shisha but more safety measures should be put to avoid possible cross infections from one person to the other while sharing the mouthpiecemale 22 years old however other participants believed that nontobacco alternatives would not be helpful rather cigarette cessation programmes should be adapted to help with quitting smoking of any kind i am a shisha smoker but i want to stop smoking completely alternatives should not be a priority to any person i believe that smoking shisha is not good and to all people who smoke should be supported to stop smoking completelyfemale 19 years old some participants also advocated for laws to reduce shisha access i smoke because i have a right to do anything i want i propose that excessive rights especially those that make people vulnerable should be reduced so as to have a healthy society otherwise it becomes hard to convince people not to take shishamale 24 years old regulations however would have to be specific to shisha and some participants did not think general tobacco legislation applied in uk there is a general regulation about tobacco use but i think specific regulations should be adopted so as to reduce shisha use in our communitiesfemale 19 years old another participant believed that use of their peers to pass on information that would help peers to change their behaviour would be of help use of people who previously used shisha in their life in giving information about the effects of shisha to fellow youth would be of helpfemale 21 years old finally other participants suggested that alternative forms of socialising like sports and drama would help reduce shisha smoking instead of going to shisha cafes as a socialising setting we young people should get involved in sports like playing football volleyball and netball or even get involved dance and drama aimed at educating other young peoplemale 21 years old its more healthy for us as young people to get involved in sports than smoking shishafemale 20 years old discussion this study found that shisha cafes provide a place for people to come together and find pleasure shisha use is voluntary but also influenced by peers and other cultural expectations despite being pleasurable many participants recognised the harm that can arise through shisha smoking and suggested various individuallevel and communitylevel interventions to reduce it several promising interventions based on recommendations found on this study include peerbased interventions alternative social events and informed legislation peerbased interventions may be appealing as they have been shown to be acceptable feasible and low cost in other settings especially in comparison to more formal interventions that rely on professional healthcare providers peers share common characteristics circumstances and experiencesall of which are thought to facilitate their acceptability to target populations and increase their influence and authenticity 32 prior research has shown that people are more likely to hear and internalise messages and thus to change their attitudes and behaviours if they believe the messenger is similar to them and faces the same concerns and pressures that they face 33 34 importantly peerbased interventions have been successful in projects aimed at reducing the incidence of cigarette smoking among young people 35 a study involving an informal schoolbased peerled intervention for smoking prevention in adolescents showed a reduction of 22 in the odds of being a regular smoker compared with a control 36 these types of interventions could be readily adapted for use with shisha smoking promotion of alternative social events is another promising intervention approach to reduce shisha smoking among young people examples include sports music dance and drama among others the mechanism of effect may lie in the fact that social events enable people of compatible backgrounds to come together to achieve a common goal 37 for example some studies on sports show that participants are linked by shared perspectives language and activities thus creating a shared network and bonds that go beyond a desire to compete 38 other studies on sport participation also place emphasis on the value of shared experiences and linkages to others 39 sports may also be used to pass on information in different areas educative sessions for instance may be provided during or after sport events coaches teammates and other respected persons may serve as guest speakers to engage the audience this approach was taken in india where sexual and reproductive health including hiv aids and life skills to empower youth has been integrated with sports 40 drama has been widely employed in prevention of hivaids through community mobilisation and raising awareness in uganda and south africa 41 also in a study from india use of information education and communication activities in the form of drama and folk dances have shown success in increasing awareness about hivaids from 58 to 70 and in increasing knowledge open access regarding prevention of hiv by using condoms from 42 to 61 42 informed legislation specific to shisha maybe a third avenue for reducing use of shisha major breakthroughs regarding public health policies in tackling cigarette smoking have been seen in many countries of the world including the uk some examples are smoking bans in public places tax policies and limits on smoking advertisements 43 several studies aimed at reducing tobacco use globally have shown that increasing taxes on tobacco products can be used as a tobacco control strategy as long as this strategy is well implemented 44 high prices can greatly reduce tobacco use 45 studies from highincome countries find that an increase of 10 in price will reduce the overall use of tobacco by 4 on average 45 results were even more pronounced in lowmiddleincome countries however most of the regulations and policies are focused on cigarettes rather than other types of tobacco products like shisha 7 46 in many countries including the uk shisha is exempted from tobacco policies including reduced means of enforcing relevant policies to control tobacco this situation has contributed to the explosion of shisha cafes and restaurants across the globe 7 46 lessons learnt from anticigarette campaigns need to be applied to shisha smoking as well two aspects of shisha warrant unique legislation the first is related to packaging and associated warning labels 47 globally the packaging of cigarettes is nearly uniform with the same number of cigarettes in the similarly sized packs and cartons in contrast shisha is packaged in various amounts and in differently shaped containers moreover shisha is often used communally and individuals may not see the packaging shisha users may therefore be unaware of the risks related to the tobacco burning charcoal or even the infections that would spread through sharing of the waterpipe 7 48 49 nonremovable labelling may be needed for the waterpipes specifically recently some countries have started to implement policies for warning labels on shisha packaging in turkey for instance legislation dictates that these labels should be placed on all the shisha packaging covering at least 65 of the package 50 second flavoured shisha has a small amount of tobacco relative to the profit margin 25 policies aimed specifically at tobacco only may therefore be inadequate and specific legislation aimed at flavoured shisha may be needed to be effective conclusion shisha use is rising and may pose significant health risks for those who smoke it and those who are exposed to it this study provides informative perspectives on the role shisha plays in social interactions factors influencing shisha use and potential means for reducing it future work should focus on intervention development to prevent the negative individual and public health consequences of shisha use without sacrificing the importance of social interactions

objectives to explore 1 the social function of shisha cafes for young people living in the uk and 2 other alternative activities existing or potential that do not involve tobacco smoking methods we conducted qualitative interviews with young adults age 1830 in leeds uk snowballing sampling was used in selecting the participants interviews were audiorecorded and explored the perspectives and experiences of young people in as well as potential alternative activities data were transcribed and analysed thematically results shisha use plays a central role in social interactions youth described using shisha because of emotional and sensory pleasure shisha use was implicitly endorsed by respected professionals such as doctors and university lecturers who were seen smoking it most but not all shisha smokers acknowledged that shisha use is harmful suggestions for reducing shisha use included use of nontobacco alternatives legislation to reduce access and alternative means for socialising such as sports conclusion for young people in the uk the known health dangers of shisha are outweighed by its social benefits and shisha is perceived as acceptable interventions to reverse the increase in shisha cafes should focus on both individual smoker as well as the community without sacrificing the importance of social interactions

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introduction language acquisition extends far beyond grammar and vocabulary it delves into the intricacies of sociolinguistic competence essential for effective communication imagine two individuals both fluent speakers of a language yet one adeptly navigating social nuances while the other struggles this discrepancy underscores the significance of sociolinguistic competence and its link to speaking proficiency among language learners the field of sociolinguistics has long recognized language as a multifaceted tool shaped by social contexts while studies have dissected linguistic structures the correlation between sociolinguistic competence and speaking proficiency remains a focal point shaping the landscape of language acquisition explorations into this nexus have uncovered fundamental yet evolving patterns in language learning urging further investigation into its depths within this context this research probes the intricate relationship between sociolinguistic competence and speaking proficiency among language learners the specific problem lies in delineating the extent to which sociolinguistic competence influences speaking proficiency and vice versa among individuals engaged in language acquisition recent empirical evidence indicates that sociolinguistic competence significantly impacts an individuals speaking proficiency studies suggest that an individuals ability to comprehend and appropriately utilize linguistic markers of social relations politeness conventions register differences dialects and accents greatly influences their spoken communication prowess conversely ones proficiency in verbal communication may also mould their sociolinguistic competence illustrating a dynamic relationship between the two facets of language acquisition studies have shown that individuals with high sociolinguistic competence tend to exhibit superior speaking proficiency navigating diverse social contexts with linguistic dexterity on the other hand individuals struggling with spoken communication often exhibit deficits in sociolinguistic knowledge impeding their ability to effectively convey intended meanings navigating through this uncharted terrain the primary objective of this study is to unravel the interconnectedness of sociolinguistic competence and speaking proficiency by employing a mixedmethods approach integrating quantitative assessments and qualitative insights this research aims to not only identify correlations but also elucidate the underlying dynamics shaping language learners abilities in social language use and verbal communication through this endeavour the study endeavours to contribute a nuanced understanding that transcends conventional language learning paradigms offering insights into the integral relationship between sociolinguistic competence and speaking proficiency among language learners sociolinguistic competence encompasses a comprehensive set of skills essential for effective communication within diverse social contexts it refers to an individuals ability to comprehend and appropriately use linguistic markers adapting language to suit various social situations and navigate interactions within a particular speech community the multifaceted nature of sociolinguistic competence involves several components first understanding social contexts individuals with high sociolinguistic competence possess a keen awareness of social settings deborah schiffrin 2006gordon 2010 comprehending the appropriate linguistic choices and behaviours expected in various contexts such as formal versus informal situations or interactions among different social groups second politeness and register proficiency in sociolinguistic competence also involves the ability to gauge and utilize appropriate politeness strategies and linguistic registers according to the formality and social hierarchy of the communication setting the last dialects and accents competence in sociolinguistics encompasses the ability to comprehend and use dialectal variations and accents within a language demonstrating flexibility in language usage across diverse linguistic communities the exploration of sociolinguistic competence and speaking proficiency among language learners within existing literature exposes critical limitations predominantly research endeavours have been confined to specific language learner groups primarily situated in controlled environments within englishspeaking countries this restricted focus has inadequately represented the broader spectrum of language learners excluding diverse linguistic and cultural contexts moreover the literature predominantly concentrates on establishing statistical correlations between sociolinguistic competence and speaking proficiency often overlooking contextual intricacies and sociocultural factors influencing language acquisition an alternative discourse within the literature acknowledges the potential complexity inherent in the correlation between sociolinguistic competence and speaking proficiency among language learners this recognition emphasizes the necessity for comprehensive research designs that transcend the limitations of quantitative approaches studies such as stress the need for nuanced investigations that amalgamate both quantitative and qualitative methodologies these methodologies delve deeper into contextual nuances learning strategies and sociocultural influences offering a more holistic understanding of the relationship between sociolinguistic competence and speaking proficiency among language learners further exploration into factors influencing the correlation between sociolinguistic competence and speaking proficiency sheds light on the multifaceted nature of this relationship varied factors including the sociocultural background of learners the context of language acquisition and the adaptability of learners to diverse linguistic environments significantly impact the manifestation of sociolinguistic competence in speaking proficiency additionally the exclusive emphasis on quantitative measurements fails to encompass the richness of qualitative insights into language learners experiences limiting the comprehensive understanding of sociolinguistic competence acquisition in conclusion the existing literature on sociolinguistic competence and speaking proficiency among language learners is replete with limitations largely stemming from the narrow scope of research methodologies and confined contexts this lacuna necessitates a paradigm shift in research design advocating for more inclusive approaches that amalgamate quantitative and qualitative methodologies bridging this gap demands an exploration of sociolinguistic competence and speaking proficiency beyond statistical correlations considering contextual nuances sociocultural influences and qualitative insights hence this study endeavors to probe the intricate relationship between sociolinguistic competence and speaking proficiency in language learners aiming to offer a more holistic comprehension through a mixedmethods approach method this research employed a mixedmethods research design integrating both quantitative and qualitative methodologies to achieve a comprehensive exploration of sociolinguistic competence and speaking proficiency in language learners by combining these methodological approaches diverse data sources and perspectives were gathered and analyzed presenting a multifaceted understanding of the research topic this inclusive approach facilitated data triangulation and the incorporation of varied viewpoints enhancing the depth and robustness of the studys insights into the correlation between sociolinguistic competence and speaking proficiency among language learners the study participants included 65 participants were recruited from various universities across lamongan regency indonesia the chosen sample aims to represent a diverse crosssection of language learners across different age brackets linguistic backgrounds and proficiency levels considerable attention was paid to gender balance socioeconomic diversity and cultural variations within the selected cohort to ensure a comprehensive and inclusive representation criteria for participant inclusion were primarily based on language proficiency levels in the target language prospective participants underwent assessments to ensure a certain level of competence in the designated language additionally participants were chosen to encompass a broad spectrum of sociolinguistic backgrounds and experiences ensuring diverse perspectives and enriching the depth of the studys analysis these inclusion criteria aimed to facilitate a comprehensive examination of the correlation between sociolinguistic competence and speaking proficiency among language learners the study employed a comprehensive array of instruments to evaluate participants language proficiency and sociolinguistic competence specifically the test of english as a foreign language was exclusively utilized as the standardized language proficiency assessment to objectively evaluate participants speaking proficiency toefl was meticulously chosen for its established credibility in measuring speaking skills aiming to provide a rigorous and uniform assessment framework ensuring a comprehensive nur fariha khoirul anwar nirwanto maruf exploring the correlation of sociolinguistic competence and speaking proficiency and how learners perceived them 1004 evaluation of language proficiency levels among the participants additionally structured surveys or questionnaires were designed to focus on sociolinguistic competence allowing inquiries about language use in diverse social contexts perceptions about dialects and reactions to specific sociolinguistic scenarios in addition to the toefl test and questionnaires for quantitative data qualitative data were gathered using semistructured interviews these interviews employed openended questions to delve into participants experiences beliefs and attitudes toward language use across diverse social settings by exploring sociolinguistic norms preferences and challenges encountered during communicative contexts the interviews provided comprehensive insights into participants sociolinguistic experiences the research employed a diverse range of instruments to comprehensively evaluate participants language proficiency and sociolinguistic competence specifically the test of english as a foreign language served as the standardized assessment tool exclusively used to objectively evaluate participants speaking proficiency chosen for its established credibility in measuring speaking skills the toefl test aimed to offer a rigorous and standardized assessment framework ensuring a comprehensive evaluation of language proficiency levels among the participants this standardized assessment provided a reliable foundation for gauging participants speaking proficiency within the research cohort in parallel structured surveys and questionnaires were meticulously designed to delve into participants sociolinguistic competence these instruments focused on various aspects such as inquiries about language use in diverse social contexts perceptions about dialects and reactions to specific sociolinguistic scenarios through these surveys and questionnaires the research sought to capture and quantify participants perceptions and experiences related to sociolinguistic norms language preferences and responses to diverse communicative situations this quantitative data collection process facilitated a comprehensive understanding of participants sociolinguistic attitudes and behaviors across varied linguistic contexts in addition to the quantitative approach the research also incorporated qualitative instruments namely semistructured interviews to gather indepth insights into participants sociolinguistic experiences these interviews employed openended questions to explore participants beliefs experiences and attitudes regarding language use across diverse social settings by delving into sociolinguistic norms preferences and challenges encountered during communicative contexts the qualitative interviews provided nuanced and comprehensive insights into participants sociolinguistic experiences this qualitative data collection process complemented the quantitative methods by offering rich detailed narratives about participants sociolinguistic encounters and perceptions enriching the overall understanding of sociolinguistic competence among the research cohort results and discussion the findings of this study were derived based on the research aims that were posed at the beginning of the study these findings provide insight into the identify correlations between sociolinguistics competence with speaking proficiency of the participants and exploring sociolinguistic norms preferences and challenges encountered during communicative contexts the statistical measures presented in table 1 offer a summary of the language proficiency levels assessed through toefl scores among the participants the mean score representing the average toefl score among the group was calculated at 42431 this value provides an indication of the typical performance in speaking proficiency within the cohort the median score which stands at 427 reflects the middle value of the toefl scores when arranged in ascending order this statistic is particularly significant as it indicates that half of the participants achieved scores below 427 and the other half scored above this value moreover the standard deviation calculated at 3663 provides insight into the dispersion or variability of the toefl scores around the mean a higher standard deviation indicates that the scores are more spread out from the mean suggesting a wider range of proficiency levels within the group overall these statistical measures collectively depict the central tendency distribution and variability of language proficiency levels among the participants offering a comprehensive overview of their speaking proficiency as assessed by the toefl examination under the aspect of language use in diverse social contexts participants were queried about their language preferences in different settings around 78 indicated a preference for formal language in academic settings while 62 expressed a tendency towards using informal language among peers additionally a majority reported using a mixture of languages in multicultural settings regarding perceptions about dialects participants preferences for specific dialects in various contexts were explored a significant percentage showed a preference for their native dialect in informal settings while also acknowledging the regard for standardized dialects in formal situations the section on reactions to specific sociolinguistic scenarios highlighted participants responses to situations involving language formality and dialect familiarity many respondents expressed comfort in adapting their language use based on formality while a considerable percentage indicated discomfort with unfamiliar dialects lastly the aspects related to sociolinguistic norms and preferences revealed participants attitudes toward multilingual interactions and diverse linguistic backgrounds a substantial number of participants valued codeswitching in multilingual interactions and emphasized the importance of respecting diverse linguistic backgrounds these questionnaire results provide valuable insights into participants perceptions preferences and behaviours concerning language use across various social contexts offering a comprehensive understanding of their sociolinguistic attitudes and practices the table 3 displays the distribution of respondents based on their assessed speaking proficiency levels and the corresponding percentages within each category the category advanced indicates that 32 of the participants exhibited a high level of speaking proficiency the intermediate category comprises 45 of the respondents signifying a moderate level of speaking proficiency among this group participants categorized as basic constitute 18 of the total representing individuals with a foundational level of speaking proficiency lastly the below basic category includes 5 of the participants indicating a lower level of speaking proficiency among this smaller subset of respondents this table provides an overview of the distribution of respondents across various speaking proficiency levels offering insights into the diversity of speaking skills among the surveyed participants the results in table 4 show that for the variable sociolinguistic competence the pearson correlation coefficient was found to be 1000 indicating a perfect positive correlation with itself as expected the correlation between sociolinguistic competence and speaking proficiency yielded a pearson correlation coefficient of 688 demonstrating a strong positive correlation between these variables this suggests that as sociolinguistic competence increases there tends to be a corresponding increase in speaking proficiency among the participants similarly for speaking proficiency the pearson correlation coefficient was 688 demonstrating the same strong positive correlation with sociolinguistic competence both correlations were statistically significant at the 001 level indicating that these results are unlikely to have occurred by chance this implies a robust relationship between sociolinguistic competence and speaking proficiency among the participants in this study qualitative results themes identified in participants experiences the qualitative exploration into participants experiences illuminated several key themes shedding light on their perspectives and challenges within diverse communicative contexts the first theme is sociolinguistic norms it refers to the unwritten rules or conventions governing language use within different social contexts these norms dictate how individuals communicate express themselves and adapt their language based on the formality of the situation the cultural diversity of the participants or the setting participants in the study emphasized the importance of these norms in shaping their communication they highlighted the need to conform to established linguistic standards in formal settings to convey clarity and adherence to conventional language structures conversely in more relaxed or informal social circles participants noted a more fluid and flexible approach to language often blending dialects or languages naturally depending on the social groups composition or familiarity the following excerpts are representation of participants narratives that illustrate the theme excerpt 1 navigating different social environments demands adjusting my speech at work maintaining a professional tone with standardized language is key but with my closeknit community its much more relaxed we mix languages based on comfort excerpt 2 ive noticed that in social gatherings especially among friends from diverse backgrounds we tend to mix languages casually it feels natural to switch between languages depending on who im speaking with excerpt 3 ive noticed the formality in educational settings especially during lectures or presentations i tend to use a more structured and standardized form of language however during informal gatherings i embrace my native dialect it feels more personal and genuine the second theme is language preferences it refers to the choices individuals make regarding the language or dialect they use in various social contexts it involves selecting a particular language style based on comfort identity or appropriateness to the situation this exploration aims to uncover participants inclinations toward specific languages or dialects in formal versus informal settings shedding light on the factors influencing their linguistic choices and expressions of identity the following excerpts are representation of participants narratives that illustrate this theme excerpt 4 my native dialect is deeply rooted in my identity i feel a sense of comfort and authenticity when conversing in my mother tongue especially in familial or casual gatherings but when im in formal settings i switch to a more standardized language to fit in excerpt 5 the choice of language depends on the situation when im in a formal context i prefer using the language ive been taught in school or learned through textbooks but informally i tend to switch to a blend of languages it feels more natural and relaxed excerpt 6 for me its not just about language its also about culture and identity using my native dialect with my community fosters a sense of belonging and comfort however in academic navigating conversations in multilingual environments demands constant vigilance theres always the risk of misinterpretation especially when idioms or cultural references dont translate well its a constant effort to ensure everyone is on the same page the qualitative exploration into participants experiences vividly illuminated various facets of language use unveiling the intricacies embedded within sociolinguistic norms language preferences and challenges encountered in multilingual contexts participants conveyed a profound understanding of the subtle yet influential nuances shaping their linguistic interactions across diverse social settings these insights encapsulated in their narratives highlighted the adaptability in language use the interplay between formal and informal language choices and the complexities inherent in multilingual environments the depth and richness of their experiences underscore the multifaceted nature of language emphasizing its profound connection to identity culture and effective communication across diverse linguistic landscapes the findings of this study shed light on the intricate relationship between sociolinguistic competence and speaking proficiency among language learners the research integrated a mixedmethods approach utilizing both quantitative and qualitative instruments to comprehensively explore these interconnected aspects the quantitative analysis revealed a significant correlation between sociolinguistic competence and speaking proficiency as evidenced by the pearson correlation coefficient these findings align with prior research emphasizing the strong association between sociolinguistic understanding and verbal communication abilities participants toefl scores provided valuable insights into their speaking proficiency showcasing a mean score of 42431 and a standard deviation of 3663 this illustrates the overall performance and variability in language proficiency within the research cohort the findings of this study significantly echo and bolster the established body of academic literature underscoring the profound importance of sociolinguistic competence in both language acquisition and proficient communication across diverse social environments this resonance notably aligns with the seminal works of booven and thaler whose research prominently emphasized the indispensable role of sociolinguistic awareness in facilitating language learning and fostering effective communicative skills furthermore these outcomes fortify the assertions previously elucidated by minggirovna whose comprehensive exploration highlighted the intricate correlation between language proficiency and sociocultural comprehension additionally the present findings are in congruence with prior research emphasizing the critical significance of sociolinguistic competence in language acquisition and successful communication the established correlations between sociolinguistic competence and speaking proficiency underscore the intrinsic relationship between language proficiency and the understanding of sociocultural nuances this alignment significantly underscores the consistent importance of sociolinguistic competence in molding and shaping communicative capabilities among language learners moreover the qualitative insights gleaned from this research resonate with earlier scholarly works that have explored sociolinguistic norms language preferences and challenges encountered in communicative contexts the narratives collected in this study echo existing literature emphasizing the role of societal and cultural factors in shaping language use across various social settings the nuanced depiction of language choices adapting speech based on context and challenges in multilingual environments resonates with the broader discourse on sociolinguistics however it is essential to note both consistencies and divergences between this studys findings and prior literature while the correlations established between sociolinguistic competence and speaking proficiency align with existing knowledge the qualitative nuances in participants experiences offer richer insights into how sociolinguistic norms and preferences manifest in reallife communicative situations these qualitative dimensions might diverge from traditional linguistic research methodologies offering more detailed narratives and personalized experiences that enhance our understanding of sociolinguistic interactions in essence this studys findings corroborate established notions while also contributing nuanced perspectives that enrich the broader discourse on sociolinguistic competence and language proficiency the integration of qualitative data with quantitative correlations offers a comprehensive understanding of the intricate relationship between language learning sociolinguistic competence and communicative effectiveness providing a valuable contribution to the existing body of literature in this field conclusion the culmination of this research reveals critical insights into the interconnectedness of sociolinguistic competence and speaking proficiency among language learners through a mixedmethods approach encompassing both quantitative and qualitative analyses this study illuminated the significance of sociolinguistic factors in shaping communicative abilities the quantitative analysis marked by the pearson productmoment correlation coefficient showcased a substantial correlation between sociolinguistic competence and speaking proficiency as evidenced by the toefl scores moreover qualitative narratives gleaned from semistructured interviews unveiled multifaceted dimensions of sociolinguistic norms language preferences and challenges faced in diverse communicative contexts this study integrates various key points underscoring the pivotal role of sociolinguistic competence in language acquisition and communicative success it solidifies existing literature highlighting the intricate relationship between language proficiency and sociocultural understanding emphasizing the necessity of navigating sociolinguistic complexities within diverse social settings the studys outcomes imply profound implications for language education and pedagogy advocating for a more nuanced approach to teaching that integrates sociolinguistic elements into language programs understanding sociolinguistic norms and preferences is crucial for learners to attain communicative efficacy in diverse social milieus however several questions persist warranting further investigation future research endeavours should delve deeper into the mechanisms linking sociolinguistic competence and speaking proficiency exploring the role of culture identity and pedagogical approaches in language learning in conclusion this study contributes a comprehensive understanding of the intricate dynamics between sociolinguistic competence and speaking proficiency it calls for a paradigm shift in language education stressing the imperative role of sociolinguistic awareness in fostering effective communication as we navigate the complexities of language learning embracing sociolinguistic nuances becomes not just a necessity but a cornerstone in achieving communicative success and cultural integration acknowledgement i would like to express my sincere gratitude to dr nirwanto maruf and prof dr khoirul anwar mpd for their assistances to share their knowledges experiences and insights in completing this article i would like to thank all of the individuals who provided support and assistance during the data collection and analysis phases of this study their contributions have been greatly appreciated

this study aims to explore the correlation between sociolinguistic competence and speaking proficiency in language learners while examining their perceptions of these aspects conducted using a mixedmethods approach the research gathered data from 65 participants across multiple universities in lamongan regency east java indonesia quantitative analysis involved test of english as a foreign language toefl scores structured surveys and questionnaires assessing sociolinguistic competence qualitative insights were obtained from indepth interviews illuminating participants experiences beliefs and challenges in diverse social settings related to language use quantitative findings indicate a strong correlation between sociolinguistic competence and speaking proficiency the pearson correlation coefficient for sociolinguistic competence was 1000 confirming a perfect positive correlation while the correlation between sociolinguistic competence and speaking proficiency was 688 signifying a robust positive correlation similarly speaking proficiency exhibited a 688 correlation with sociolinguistic competence qualitative insights emphasized themes such as sociolinguistic norms language preferences and challenges in communicative contexts participants stressed the importance of adhering to sociolinguistic norms showcased preferences for specific language styles in diverse contexts and highlighted challenges in multilingual environments the study solidifies the significant correlation between sociolinguistic competence and speaking proficiency among participants emphasizing the pivotal role of sociolinguistic competence in enhancing speaking proficiency these outcomes stress the reciprocal influence between these dimensions in language learning emphasizing the need for tailored language learning strategies incorporating sociocultural dimensions future research may delve into implementing sociolinguistic approaches in language education to enhance learners communicative skills and sociolinguistic awareness

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introduction the wide adoption of mobile phones internet services social media platforms and the proliferation of wearable devices and connected objects have resulted in a massive production of personal data that characterize many aspects of daily life at extremely fine temporal and spatial granularities lane et al 2010madan et al 2012bettini and riboni 2015 the availability of such a huge amount of data represents an invaluable resource for designing and building systems able to understand people as well as communities needs and activities so as to provide tailored feedback and services lathia et al 2013 at the same time an increasing number of applications makes it easier for people to share their personal information across many social networking applications and mobile apps hsieh et al 2007miluzzo et al 2008tang et al 2006 these scenarios however raise unprecedented privacy challenges and concerns with users being continuously called to take decisions concerning the disclosure of their personal information on the basis of a difficult tradeoff between data protection given the potential for user identification de montjoye et al 2013de montjoye et al 2015rossi and musolesi 2014rossi and musolesi 2015 and the advantages stemming from data sharing acquisti et al 2015 several researchers have therefore started investigating the role of various factors in influencing the attitude towards data disclosure eg interpersonal relationships consolvo et al 2005wiese et al 2011 user characteristics such as gender hoy and milne 2010 age christofides et al 2012 or personality traits quercia et al 2012schrammel et al 2009 and the type of the shared data knijnenburg et al 2013 our study makes a step further in this direction besides considering only demographics selfreported personality traits and privacy dispositions our work takes into account the role played by behavioral information about social interactions and mobility patterns extracted by the users mobile phone we focus in particular on the sharing of information about locations and social interactions data types in order to investigate all these factors we ran a fieldstudy with a community of 63 subjects they were provided with a smartphone incorporating a sensing software explicitly designed for collecting mobile phone data and a personal data store a system meant to both enable subjects to raise awareness of their data and to control their disclosure with the other members of the community as well as to keep track of their actual sharing behavior a relevant aspect of our approach is that we observe the actual sharing behavior on real user data rather than attitudes expressed through questionnaires personal data stores are systems designed to provide users with control over their personal data disclosing choices towards thirdparties more specifically such systems enable services to access personal data and metadata through mechanisms preserving users privacy mun et al 2010moiso et al 2012de montjoye et al 2014 by design they are meant to create a trusted environment where several other mobileweb services eg using communication location or sensor data interact with the user in addition users can actively see their data being fed to the online services and the potential benefit they receive from them we may think about a scenario where the personal information derived from the internet services and from the pds can be used for the design and enhancement of privacypreserving systems a designer could imagine to personalize default privacy settings or to recommend sharing policies in an adaptive way by using the most informative behavioral features our results show that it is possible to identify disclosing information behavioral routines by extracting features for example from call and sms data or a pds internet service in other words we can single out key factors that can be used to understand users privacy related behaviors moreover we can highlight meaningful combinations of factors derived from mobile data behavioral patterns of a pds internet service or anonymous or not understanding the factors affecting personal mobile data disclosure a3 individual characteristics that maximize the understanding of the issues related to the disclosure of personal data such potential could encourage the development of internet services towards a more transparent direction the main contributions of this work can be summarized as follows first we run a fieldstudy within a livinglab where people share continuously their real data in this experimental setting we capture the dynamic sharing behavior of users concerning personal information and not just a static choice second we compute several families of features related not only to selfreported demographics personality traits and privacy attitudes but also behavioral communication and mobility information captured by mobile phones as well as usage patterns extracted from a pds finally we experimentally evaluate and highlight the effects of those factors on the choice users make when selecting their privacy settings for two particular types of personal data location and social interactions related work previous research has considered a number of factors that can explain individual attitudes and preferences toward disclosing personal information demographic characteristics such as gender and age have been found to affect disclosure attitudes and behavior several studies have identified gender differences concerning privacy concerns and consequent information disclosure behaviors for example women are generally more protective of their online privacy with regard to the amount of data disclosed on social networking platforms hoy and milne 2010 similarly in a study on facebook usage fogel and nehmad 2009 found that women are less likely than men to share personal data such as instant messenger address home place or phone number on their profile page age also plays a role in affecting information disclosure behavior for example in a study with 288 adolescents and 285 adults on facebook usage christofides et al 2012 found that adolescents disclose more information than adults prior work also emphasizes the role of personality traits eg individual stable psychological attributes to explain risk perception and consequent information disclosure behavior korzaan et al 2009 explored the role of the big5 personality traits costa and mccrae 2008 and found that agreeableness defined as being sympathetic straightforward and selfless has a significant influence on individual concerns for information privacy junglas et al 2008 and amichaihamburger and vinitzky 2010 again used the big5 personality traits and found that agreeableness conscientiousness and openness to experience affect the concern for privacy however other studies targeting the influence of personality traits did not find significant correlations schrammel et al 2009massa et al 2015 an interesting and extensive study is that conducted by quercia et al 2012 with 1313 facebook users in us the authors investigated the role of the big5 personality traits and they found weak correlations among openness to experience and to a lesser extent extraversion and the disclosure attitudes on facebook in 2010 lo 2010 suggested that locus of control rotter 1966 could affect individual perception of risk in disclosing personal information with internals being more likely than externals to feel that they can control the risk of becoming privacy victims hence more willing to discloseshare their personal information additional work has also showed a positive association between users sociability captured by their personal network size and the subjects behavior with respect to information disclosure subjects characterized with high sociability tend to share more information and to have less privacy concerns young and quanhaase 2009 building on these findings and following the suggestions by jensen et al 2005 our work connects demographic factors individual traits and dispositions to the actual sharing behavior of people rather than attitudes expressed through questionnaires moreover we focus our attention not only on demographic factors individual traits and dispositions but also on behaviors directly measured from the data themselves field study in this section we describe the methodology followed during our 15week study the living laboratory we conducted our field study within the mobile territorial lab project 2012 a longterm living lab launched in november 2012 as a joint effort between industrial and academic research institutions centellegher et al 2016 it consists of a group of volunteers who carry in their daily life an instrumented smartphone in exchange for a monthly credit bonus of voice sms and data access specifically participants are provided with an androidbased smartphone running a sensing software that continuously collects different types of mobile phone data aharony et al 2011 and a tool called personal data store de montjoye et al 2014 which stores the participants information and enables himher to exercise full control on own data management vescovi et al 2014 by using the pds subjects can decide at any time about whether and how to disclose their data to the other participants one of the most important characteristics of mtl is its ecological validity given that the participants behaviors are sensed in the real world as people live their everyday life and not under artificial laboratory conditions all volunteers were recruited within the target group of young families with children using a snowball sampling approach where study subjects recruit future subjects from among their acquaintances goodman et al 1961 upon agreeing to the terms of participation the volunteers granted researchers legal access to their behavioral data collected by their smartphones however volunteers retain full rights over their personal data such that they can ask to delete the collected information from the secure storage servers moreover participants have the choice to participate or not in a specific study in the current paper we report a study conducted on 63 individuals from the mtl community participants age ranged from 28 to 46 years old they held a variety of occupations and education levels ranging from high school diplomas to phd degrees all were savvy android users who had used the smartphones provided by the living lab since 8 months before all participants lived in italy and the vast majority were of italian nationality the sample is characterized by a mediumlow social connectivity on average subjects declared to know 794 other subjects and resulted to be known by 784 in the following subsections we outline the procedure adopted for the current study and we describe more in detail the mobile sensing platform the pds and the collected data about participants demographic characteristics and individual traits experimental setup the study took place for 15 weeks from july to november of 2013 before the official beginning of the study participants were asked to fill a survey including scales targeting big5 personality traits perugini and di blas 2002 locus of control farma and cortivonis 2000 dispositional trust mayer and davis 1999 selfdisclosure cozby 1973 and privacy concerns smith et al 1996 anonymous or not understanding the factors affecting personal mobile data disclosure a5 on the first day of the study participants were asked to set their initial disclosure preferences on the privacy setting area provided by the pds from that time on subjects were free to change their setting at will and at any time a week after we started providing subjects with the social views built from the data disclosed in the community both the individual and the social views are generated by the pds at the end of the study subjects were asked to set their final sharing preferences on the pds mobile sensing platform the sensing software runs in a passive manner and does not interfere with the normal usage of the phone the configuration is set in a way that batteryintensive actions are performed in intervals allowing usefulness while minimizing battery consumption the data collected consisted of i call logs ii sms logs iii proximity data obtained by scanning nearby phones and other bluetooth devices and iv location data obtained using gps or localized wifi bluetooth and gps scans were done every 5 minutes note that in this study we use 5months of collected data to compute several behavioral features personal data store the pds is a digital space owned and controlled through a web interface by the user acting as repository for the personal information collected during the study and offering every user the possibility to view control and disclose herhis own data data were organized in regions by putting together data having a similar meaning one section of the pds was designed to provide users with visualizations of their personal data two types of individual views were provided for each kind of owned data a detailed view where every available piece of raw data is represented in detail and aggregated views with aggregations at different levels of the personal data the pds also features a sharing area vescovi et al 2014 a space for subjects to fix the desired disclosure level of their data distinguished into do not share share anonymously share nonanonymously finally subjects choices are directly reflected into social views shown in figure 2 and built out of the personal data disclosed by the participants social views were accessible any time by the participants on their pds in such a way that any change through the sharingdisclosure settings had an immediate effect on the material displayed in them this enabled levels of comparison of one subjects behavior with those of the others that depended on the subjects current sharing settings in more detail a if for a given person a given data type and a given time the setting was do not share then the corresponding social views did not exploit the corresponding data and the user was prevented to access any of them b if the setting was share anonymously then only their aggregated and anonymous data were made available in social views and they could access data only in the same format c with a share nonanonymously setting the relevant data were presented with information about the subject and the latter was enabled to access all the similarly disclosed information by the other users in summary the level of disclosure and the social views worked in full synchrony to ensure that the higher the chosen disclosure level the more detailed was the information made available and accessible about the others with an increasing level of social comparison to exemplify views such as how much am i social how long ive been on the phone wrt others for example figure 2 presents the latter example view for a user sharing herhis data nonanonymously the red column represents the user while on the horizontal axis the information related to the other users sharing nonanonymously are reported anonymous or not understanding the factors affecting personal mobile data disclosure a7 fig 3 pds sharing area allows users to set their pd disclosure preferences demographics personality and other individual characteristics we collected different types of information from our subjects including demographics selfreported personality traits and attitudes towards privacy descriptive information for the following scale scores is provided in table ii demographic information as pointed out in section 2 there have been several attempts to associate privacy concerns and sharing behavior with demographic information in our case we used participants age and gender personality and individual traits in our study big5 personality traits are measured by means of the bfms questionnaire perugini and di blas 2002 a scale validated for italian covering the traditional dimensions of extraversion neuroticism agreeableness conscientiousness and openness to experience the scale consists of 10 adjectives per personality trait with a rating scale from 1 to 7 the big5 personality traits scores are obtained by summing the points of each of the 10 adjectives we also exploited the locus of control rotter 1966 a psychological construct measuring whether causal attribution for ones behavior or beliefs is made to oneself or to external events or circumstances the corresponding scale consists of a set of beliefs about whether the outcomes of ones actions are dependent upon what the subject does or upon events outside of herhis control locus of control was measured by asking subjects to fill the italian version of craigs locus of control scale farma and cortivonis 2000 this scale is composed of 17 questions using a rating scale from 0 to 5 each participants locus of control score is computed by summing up the points of each item another construct we take into account is the dispositional trust rotter 1967 was among the first to discuss trust as a form of personality trait defining interpersonal trust as a generalized expectancy that the words or promises of others can be relied on in our study we resort to mayer and davis 1999 trust propensity scale the dispositional trust scale has 8 itemquestions measured in a 1 to 7 point scale to acquire the final trust score for each subject we sum up the points of each item finally we targeted the selfdisclosure attitudes of our subjects selfdisclosure has been defined as any message about the self that an individual communicates to another one cozby 1973 we use wheelesss scale which has been utilized to measure selfdisclosure in online communication and in interpersonal relationships wheeless and grotz 1976 precisely we measure five dimensions of selfdisclosure using a 17 scale for each namely amount of disclosure positivenegative nature of disclosure consciously intended disclosure honesty ac smith et al 1996 this scale regards privacy concerns of the individual about organizational information privacy practices with four datarelated dimensions collection unauthorized secondary use errors and improper access to personal information the concerns are measured using a 1 to 7 point scale consisting of 15 questionitems the final score is computed by summing all the responses to the questions social relationships within the community each user was asked to indicate the people known within the community methodology our goal is to understand the effect of a wide range of variables in the disclosing decisions people make about their personal mobile data to do this we make two concrete steps firstly we fit binary logistic regression models testing separately how the sharing choices are affected by the following set of independent variables families demographic information psychological traits and other individual dispositions social relationships within the community dynamic behavior and pds access usage information as visualized in table ii note that testing separately pergroup represents a feature selection step since we use backward elimination secondly taking into account exactly those features that showed a significant effect we construct an overall and a combined mobilepds blr classification model per data type in order to predict the sharing choices the overall models represent the most effective predictors from the different families while the combined models use only behavioral mobile data and pds usage access features such data could actually be collected using a pds service in a reallife scenario dependent variables sharing choices to model the disclosure of personal information we construct dependent variables taking into account the final disclosing choices subjects set in the pds one for each different data type sharing location and sharing interactions as said users were able to choose among three levels of sharing ie do not share share anonymously and share nonanonymously for each data type we observe from table i that the do not share choice has few occurrences concerning both the location and the social interactions data for this reason we discarded the data instances for the sharing choice do not share for both data types anonymous or not understanding the factors affecting personal mobile data disclosure a9 42 independent variables 421 demographics personality and other individual characteristics in this paper we take into account several characteristics of our study participants specifically we focus on demographic data big5 personality traits locus of control dispositional trust a measure of privacy concerns and the five variables describing selfdisclosure furthermore features regarding participants social network were extracted using the selfreported information provided about the acquaintance level with the other people inside the community more specifically the following variables have been computed outdegree and indegree all variables describing individuals characteristics are normalized scalar variables except gender being a categorical dichotomous variable notice also that it was not possible to understand how the choice of a friend affects the disclosing option because subjects are not aware of the identity of the other users privacy setting in the best case if both parties share openly the data they could see each other demographic information but not the name therefore we focused our analysis on features that characterize their social network size ie inoutdegree 422 dynamic behavioral data we computed a number of features from participants mobile phone usage behavior willing to examine if they could associate with personal information disclosure decisions in table ii all the behavioral features appear combined with descriptive information firstly we consider location and social interaction information collected passively from the mobile phone for both social interaction data we compute the following five features adjusted to each data type context as shown in table ii the first three concern the whole period of the study while the last two ones quantify a daily behavior taking into account the days that users were actively communicating note that our community is really active thus for a participant the total days of active communication is almost equal to the days of the study the features are the total number of calls and sms we also consider the number of unique calls contacts and sms contacts and the calls and sms diversity this measure of diversity eagle et al 2010 quantifies how the individuals spread their time among their contacts more precisely it is given by the following formula d k j1 p ij log p ij log k where p ij is the volume of communication interactions between subject i and j normalized by the total number of i s calls or sms and k is the distinct number of individuals contacted by calls or sms respectively high values of the diversity measure indicate that participants distribute their time more evenly among their contacts finally we extract the daily average and standard deviation of the calls and sms events using the days when users were active to characterize participants mobility behavior we extract metrics quantifying amount and deviation of the movement recently used by canzian and musolesi 2015 regarding the amount we compute the total distance covered by the subject ie the sum of the geodesic distance of the subsequent latitude and longitude coordinate pairs during the 5 months period in addition based on the days the user was found active we compute the daily average distance covered note that we exclude coordinates not matching italys territory for two reasons to capture everyday life behavior and to avoid outliers generated by very high distances inbetween countries when traveling those features capture the amount of mobility of a subject next we measure the standard deviation of displacements where displacement stands for the distance between one visited pair of coordinates and the subsequent one this measure quantifies how much each location transition refrains from the total user movement we also include the daily average for the standard deviation of displacements quantifying a deviation of the visited locations from the average daily movement 423 personal data store usage we also investigated the role played by personal data store usage by computing the total number of distinct days participants accessed the individual views and the social views for both location and interaction data types those metrics will provide us with insights of how users used the tool and which kind of feedback they visited more often per data type logistic regression analysis and classification as previously mentioned we first investigate the predictive role played by the different groups of independent variables then using for each group only the factors showing a significant effect we build a combined mobilepds and an overall model for our anonymous or not understanding the factors affecting personal mobile data disclosure a11 two dependent variables sharing location and sharing interactions features included in all models are selected by using backward elimination for crossvalidation we use a leaveonesubjectout approach as evaluation metrics we report the cox snells and the nagelkerke pseudo r 2 measures to indicate the variance explained by the models specifically cox snells r 2 calculates the proportion of unexplained variance which is reduced as we add more variables to the model hardin et al 2007 however the maximum value of cox snells r 2 can be less than 1 making it difficult to interpret instead the nagelkerke r 2 varies from 0 to 1 and it is easier to interpret the assessment of the goodnessoffit for the models is illustrated by the hosmer lemeshow test it tests the hypothesis h 0 the model is fit all p 005 reject the null hypothesis h 0 meaning that the model poorly fits the data hardin et al 2007 moreover for each model we provide a classification accuracy measure for the privacy choices share anonymously and share nonanonymously the strong relationships among the independent variables within each group might indicate the presence of multicollinearity this is a common concern in regression resulting into high standard errors of the β coefficients and producing noninterpretable models with poor fit especially for small sample sizes for example we notice very strong correlations between the total values and the daily averaged values of the mobile features for this reason we test them separately obtaining the same models additionally we report significant correlations between the dichotomous categorical dependent variables and the independent by applying the pointbiserial r bp coefficient results testing groups of predictors 511 demographic information our results show that age and gender do not affect the sharing choices on location and interaction data the χ 2 independence test for both dvs using gender shows that their independence was not significantly rejected hence we do not observe any gender difference in the sharing choice for both data types concerning the age factor we do not discover any association with the two dependent variables finally we do not observe any significant effect in the regression tasks using the age and gender variables 512 personality selfdisclosure and other traits interestingly it seems that selfdisclosure affects the sharing choices while the big5 personality traits and the other individual traits do not specifically selfdisclosure factors are significantly associated with the sharing choice both for location and interaction data as shown in table iii in detail a logistic regression classifier using intentional depthintimacy and honestyaccuracy provides a considerable classification gain in comparison with a baseline model using only the intercept indeed it can predict the sharing location choice with a classification accuracy of 7049 out of the 3 features only honestyaccuracy presents a positive effect to the sharing choice turning our attention to the sharing interactions choice we observe that the effect is not so strong as the one observed for sharing location indeed we classify the sharing interactions choice with an accuracy of 629 equivalent to the one obtained using only the intercept similarly with the location data depthintimacy presents a negative effect to the choice but positivenegative a positive one table iii binary logistic regression models for sharing location and sharing interactions the presented models concern only the groups of variables yielding a significant effect an intercept model for each dv is included as a baseline predictor white cells indicate that a variable has been used as an input in a blr model variables per model obtaining a significant effect are fed to a crossvalidated logistic regression classifier classification accuracy is reported for all models interestingly the depthintimacy factor associates negatively with the sharing location and sharing interactions dvs revealing a consistent tension 5 13 community social network indegree and outdegree variables do not capture significant effects in our regression tasks 514 dynamic behavior our results show that communication factors have an impact on the sharing choices of our study participants while the mobility ones do not yield a significant effect specifically the call diversity factor associates significantly with the sharing location choice and with the sharing interactions choice other factors significantly associating with sharing location choice were the standard deviation of the daily number of calls and the standard deviation of the daily number of sms a logistic regression classifier using the three aforementioned factors classifies correctly 672 of the sharing choices in detail a unit increase in call diversity or in the standard deviation of the daily number of sms indicates an increase in the odds of sharing more openly by 1157 and 1002 respectively in contrast the standard deviation of the daily calling behavior has an opposite effect implying a decrease in the odds of 601 for the sharing interactions choice the regression model keeps only call diversity after a backward elimination step the remaining factors extracted from mobile phone data do not contribute to the model more specifically a unit increase in call diversity increases the probability that somebody chooses to share nonanonymously by 1057 the model classifies correctly the 629 of the cases equally to the baseline intercept model 515 pds usage the last group of factors contains features describing the usage of the pds interestingly the usage of the pds significantly associates with the sharing choices we find a significant positive correlation between the social views location variable and the sharing location choice thus it seems that more visits someone pays to the social views section of the pds the more openly she is about to share the location data however the logistic regression model using social views location as a unique factor predicts correctly only the 6229 of the sharing choices for the interaction data the behavior is similar to the one observed for the location data ie only social views interactions shows a positive correlation with sharing interaction dv the regression model performs slightly better than the baseline testing combinations mobilepds and overall models in this section we report the results obtained using the mobilepds model and the overall model the former represents the exploitation of behavioral data collected by many online services while the latter the usage of all relevant information to predict the sharing choice iii a unit increase in call diversity in the daily std sms and in the social views location variables increases the probability that a user shares more openly the data by 163 260 and 310 respectively practically this means that if people distribute more evenly their call interactions among their contacts increase the deviation in their daily sms communication activities and increase the number of visits to the social views section of the pds they are more prone to select the share nonanonymously choice instead an increase in the standard deviation of the daily number of calls results in a 66 decrease in the chance to share more openly turning our attention to sharing interactions the mobilepds model significantly outperforms both the outcomes of the mobile phone data model and of the pds model moreover our results show that if we have a unit of increase in call diversity and in the number of visits to the pds social views section the probability that a user shares more openly herhis interaction data increases by 140 and 150 respectively 522 overall the overall model captures the 441 of the normalized variance and obtains an accuracy value of 7868 for sharing location choice as shown in table iii the factors having a significant effect are depthintimacy call diversity and the social views location more in detail a unit of increase in the depth somebody shares information decreases 60 the probability of sharing more openly on the opposite if a study participant increases the diversity of its calls and its number of visits to the social views functionality of the pds she increases 23 and 42 times respectively the probability of sharing openly the location data for the sharing interactions choice the overall model captures 4415 of the normalized variance and classifies correctly the 7580 of the choices in particular call diversity and social views interactions variables show a positive effect while the depthintimacy a negative one moreover the positivenegative factor of the selfdisclosure scale shows a significant positive effect high values of this scale indicate that people disclose more positive information about themselves within their social circle than negative one so a unit increase in this feature increases approximately 103 the probability of sharing the interaction data more openly to exemplify people who release more positive information to others are more likely to share more openly their social interaction data discussion and conclusions in this section we discuss the theoretical and the practical implications of our work and the questions that remain open theoretical implications our findings suggest that users communication interactions as inferred through mobile phone data may provide very useful information to describe users privacy choices in disclosing personal data thus confirming the relevance of smartphone data for understanding human behavior we have shown that the diversity of calls is an important factor for predicting the sharing choice for the different data types interestingly our results are in line with those recently obtained by staiano et al 2014 in a study designed to investigate the monetary value people assign to their personal data collected by mobile phones indeed they identified differences in the bidding behaviors of the individuals which are not correlated with sociodemographic or personality traits but they are correlated with behavioral differences inferred from mobile phone activity regarding the individual characteristics depthintimacy and positivenegative disclosure features constitute useful information to detect users willingness to share personal data specifically we observed a negative effect of depthintimacy on sharing data more openly this means that if subjects disclose more in depth information within their social circle it is less likely to share communication and location information in a nonanonymous way in our setting conversely we found that people sharing more positive information with their contacts tend to disclose more information about their communication activity in a nonanonymous way on the other hand we do not observe any big5 personality trait affecting the disclosure of personal information suggesting that such decisions do not necessarily pass through our personality mechanism previous studies on the influence individual traits have on privacy attitudes and privacyrelated behaviors provide contrasting evidence some of them found weak correlations lo 2010quercia et al 2012 while others schrammel et al 2009 found no significant correlations hence our results support more the latter study but also strengthen those findings since we have obtained them within an experimentation involving a community of people sharing their data during their daily lives however we should argue that additional investigation is needed to clarify the role of individuals characteristics on personal data disclosure decisions regarding the relationship between the pds tool usage and the disclosing decisions we found that a higher number of visits to the social views functionality corresponds to a higher probability for such users to share both their location and social interactions information in a nonanonymous way this observed effect is very strong in our case and could be interpreted as people having a higher propensity to share their information if they receive useful feedback an example can be users sharing their location information in a lowrisk privacypreserving way if it would be useful for environmental studies in their territory nevertheless we must keep in mind that our experimental community environment provides subjects with a sort of confidence which may lead to increased sharing in addition it has been previously shown that providing users with control over their data could raise their awareness but it also might increase the perception of control resulting in more sharing brandimarte et al 2013 practical implications the main area in which our findings could be practically applied in the short term is privacy protection our results suggest that by simply using communication interactions a limited amount of user input or usage patterns a privacyrecommendation tool could offer a preliminary way of personalizing default privacy settings which users could then change more precisely this tool may work as a layer of a personal data store that activates some personalized privacy settings once thirdparty apps or online services perform data requests in this way the user is not called to continuously take decisions concerning the disclosure of herhis personal information in addition the exploitation of usage patterns could enhance a privacy setting recommendation by employing an auxiliary information source symeonidis and perentis 2014 concerning other available sources in a recommendation task communication diversity and selfdisclosure can be computed by using digital traces or by asking simple questions respectively our findings may also be useful to devise a tool able to inform users about the extent to which they are exposing information that is generally considered to be sensitive by their social contacts or by people with similar personalities and behaviors in this way the tool may raise the awareness of the user about herhis sharing activity under this perspective the frequency of the visits to a potential personal data intensive service could be an index used to trigger notifications to the user about critical disclosing actions it is worth noticing that nowadays different tools and services for the usercentric personal data management are emerging mun et al 2010moiso et al 2012de montjoye et al 2014vescovi et al 2014 this is a consequence of the increased public attention the privacy concerns and issues receive these concerns arise mainly from the increasing ubiquitous collection of personal data and from the unprecedented daily privacy challenges users face making constantly decisions between service usage and data protection perentis et al 2015 such concerns have been recently taken into account by policymakers as shown by the new eu directive for privacy council 2016 starting from 2018 the reform of the eu general data protection rules has the goal to introduce within the whole eu new principles such as privacy by design and by default langheinrich 2001 the right of owning a copy of the personal data and the right to be forgotten rosen 2012 in this study our findings on the factors affecting personal data disclosure could provide useful insights about the development of solutions for managing personal data limitations the study was conducted in a realsetting providing us the opportunity to understand human behavior by a combination of selfreported data mobile phone data and a real system allowing users to make decisions for the disclosing of personal information however it is important to report some limitations of the study firstly the collection of selfreported data is always prone to bias secondly despite the high level of technical support for gathering mobile data battery limitations or other issues might interfere with data collection sample size is always a concern in such research tasks but the experimental evaluation presented in this work takes into consideration potential issues like multicollinearity leading to noninterpretable models the community environment and the usage of the tool should have offered a sort of trust leading users to share their data finally the sharing option may be further divided into different levels such as sharing with a specific member of our community with people with similar behaviors or dispositions with friends etc future planned modifications on the pds platform will add these levels to the sharing option despite the aforementioned limitations our findings open interesting directions for designing systems able to support users in their decisions about information disclosure and more in general to improve the experience of sharing personal information knijnenburg and kobsa 2013 as discussed above a better understanding of factors affecting sharing decisions may support the design of adaptive systems able to suggest preselected configurations of privacy options to users thus relieving them from the task of defining them wiese et al 2011

the wide adoption of mobile devices and social media platforms have dramatically increased the collection and sharing of personal information more and more frequently users are called to take decisions concerning the disclosure of their personal information in this study we investigate the factors affecting users choices toward the disclosure of their personal data including not only their demographic and selfreported individual characteristics but also their social interactions and their mobility patterns inferred from months of mobile phone data activity we report the findings of a fieldstudy conducted with a community of 63 subjects provided with i a smartphone and ii a personal data store pds enabling them to control the disclosure of their data we monitor the sharing behavior of our participants through the pds and evaluate the contribution of different factors affecting their disclosing choices of location and social interaction data our analysis shows that social interaction inferred by mobile phones is an important factor revealing willingness to share regardless of the data type in addition we provide further insights on the individual traits relevant to the prediction of sharing behavior ccs concepts •humancentered computing → ubiquitous and mobile computing systems and tools •security and privacy → social aspects of security and privacy